United Republic of Tanzania

Ministry of Health and Social Welfare

Health Sector
Strategic Plan
July 2015 – June 2020

(HSSP IV)
Reaching all Households with
Quality Health Care
Foreword
As Tanzania strives to reach middle income status, the health sector has resolved to give
more attention to the quality of health services in tandem with the pursuit of universal
access. At the same time, better health for the entire population will be promoted through
the adoption of health in all policies.
The country has made impressive gains in reducing under-five and infant mortality, through
declines in morbidity and mortality from malaria and other childhood diseases. HIV
prevalence has also fallen. Some decline in Maternal Mortality has been noted but this was
not fast enough to reach the Millennium Development Goal (MDG) targets; Neonatal
mortality has also gone down but less than planned. The unfinished work on reaching some
of the MDG 2015 targets is taken forward in the HSSP IV, driven by the call for sustainability
under the MDG successor global theme, “Sustainable Development Goals”.

Evidence shows an epidemiological transition with non-communicable diseases showing an

upsurge and a consequent rise in health care costs. Challenges posed by current health
financing levels and modalities require change to the way financial access to health care is
organized, greater efforts on resource mobilization, transparency and social accountability,
as well as more determined measures to strengthen the health system as a whole.
This HSSP is given impetus by the Big Results Now (BRN) initiative underlining the need for
better performance of health facilities as well as individuals within the health system,
improved prioritization to attain equity in health and social welfare, and ensuring well-
stocked health facilities in terms of medicines, supplies and staff. Through the Star Rating,
quality assurance system, BRN has paved the way towards improving the quality of care at
primary level, moving our health facilities towards certification and then accreditation. Re-
commitment to community-based health care will extend coverage of key maternal and
neonatal interventions, and stronger health promotion, disease prevention and social
welfare services within Local Government Authorities (LGAs).
LGAs have been mandated to be in charge of delivering social services, and the Prime
Minister’s Office - Regional Administration and Local Government (PMO-RALG) given the
task to supervise, coordinate and monitor their activities, in line with the policies and
guidelines of the Sectoral Ministries, a key role that shall continue during HSSP IV. The
Decentralization-by-Devolution approach will continue to improve governance and
management responsibilities and capacities at the health facility level, including
strengthening the voice of citizens in health service delivery and management. Performance
management shall be emphasized at all levels of the sector to increase outputs and impact.

Integrated delivery of a reviewed package of essential healthcare interventions,

strengthened Comprehensive Council Health Planning decentralized to the facility level,
better management of health facilities at all levels, and health system strengthening in
aspects such as Integrated Logistics System, Human Resource, and District Health
Information Systems are key features to achieve harmonization and a coordinated approach.
Strengthening the health system is aimed at attainment of better health of the population.
Promotion of healthy living and an environment conducive for health protection at
households and workplaces will improve the quality of life. Prevention of communicable and
non-communicable diseases, including healthy diets and action against malnutrition, will
receive high priority at national, regional, district, community and household levels. Paid
cadres at community level for social welfare, health promotion and disease prevention will
complement measures to increase access to essential services at facilities and higher levels
of the system. Further integration of social welfare and health services and closer
collaboration with other ministries, agencies and non-governmental organisations (NGOs)
will increase accessibility to social welfare services for those most in need. Gender equity
will receive increased attention through concrete measures such as focus on prevention of
HIV amongst adolescent girls, and addressing violence against women. Equal representation
of women will be prioritised in committees and boards, and rights and obligations of duty-
bearers and rights-holders will be observed.

Tanzania has a successful Sector Wide Approach (SWAp) that will be streamlined to improve
joint planning, monitoring and implementation by all stakeholders. The Public Private
Partnership (PPP) Policy already being implemented need further enhancement. Partnership
with PMO-RALG at Central, Regional and LGAs levels focuses on administrative and
governance responsibilities. Engagement with Ministry of Finance, President’s Office Public
Service Management and health-related ministries shall address the increased financing
needs, human resource supply, deployment and retention, nutrition, water, social welfare
and environment-related issues. Government shall continue its collaboration with Faith-
Based Organisations, as well as encouraging NGOs, Community-Based Organisations and all
other private health providers to expand coverage to the population.
This HSSP is the guiding reference document for the preparation of annual plans at the
agency, department, programme, health facilities and council levels. I therefore invite you all
to consult and use it extensively for the betterment of national health and social welfare
outcomes over the next five years.

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Acknowledgement
The HSSPIV has been developed to guide the continued transformation of the health sector,
to address the unfinished MDG agenda, and the increasing demand for decentralised,
affordable, equitable and quality health services in a performance-oriented mode. In
developing this plan, an intensive and comprehensive consultative process has been
employed among health and Social welfare stakeholders, beginning with the Mid Term
Review of HSSP III, Big Results Now (BRN) prioritisation process and subsequent needs
identification.

Preparation of this document was constantly guided by the HSSP IV Steering Committee that
included participation of the Government and Non-Government stakeholders, and I would
like to thank them for this commitment which I expect to continue in the subsequent
implementation stage.

Thanks to the 14 Technical Working Groups, which grew over the course of HSSP III, for
providing a very clear gap analysis related to HSSP III implementation and hence informing
the needs for HSSP IV.

Representative participation of the Council and Regional Health Management Teams, Zonal
Resource Centres, the Prime Minister’s Office – Regional Administration and Local
Government, MOF, POPSM, civil society and the private sector significantly enhanced the
ownership of this document.

The health sector Development Partners deserve appreciation for their continued technical
and financial support towards development of this document.

I would like to specifically acknowledge the contribution in developing this document of the
Team Leader (Dr. Jaap Koot), National Consultant (Dr. Elihuruma Nangawe), Costing Expert
(Ms. Catherine Barker), the SWAp task force and the Health Sector Resource Secretariat.

The MOHSW remains committed to the dissemination and utilisation of HSSP IV for central
and decentralised annual planning, monitoring and evaluation.

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Table of Contents HSSP IV
Foreword ............................................................................................................................... i
Acknowledgement ............................................................................................................... iii
Table of Contents HSSP IV .................................................................................................... iv
Acronyms ........................................................................................................................... viii
Key Messages of HSSP IV ..................................................................................................... xii
Background ..................................................................................................................... xii
Strategic Objectives ....................................................................................................... xiii
Governance and Implementation ................................................................................... xvi
Financing HSSP IV........................................................................................................... xvi
Monitoring the HSSP IV implementation ........................................................................xvii
1 Introduction.................................................................................................................. 1
2 Government Policies ..................................................................................................... 3
2.1 General Policy Framework ....................................................................................... 3
2.1.1 Tanzania Development Vision 2025 .......................................................................................3
2.1.2 MKUKUTA and Five Years’ Development Plan 2011/12-2015/16 ........................................3
2.1.3 Big Results Now........................................................................................................................4
2.2 Health Sector Policy Framework .............................................................................. 4
2.2.1 Health Policy .............................................................................................................................4
2.2.2 MMAM......................................................................................................................................5
2.2.3 National Key Result Area in Healthcare (BRN) .......................................................................5
2.3 Health and Social Welfare Legislation, Policies and Strategies.................................. 8
3 Health and Social Welfare at a Glance ......................................................................... 10
3.1 Demography, Statistics and Structures of Health and Social Services ..................... 10
3.1.1 Tanzania Geography and Population....................................................................................10
3.1.2 Health Statistics and Trends ..................................................................................................11
3.1.3 Health and Social Welfare Service Structure .......................................................................12
3.1.4 Management of Health and Social Welfare Services ..........................................................13
3.2 Service Delivery of the Health and Social Welfare Sector ....................................... 15
3.2.1 Services in Community and Health Institutions...................................................................15
3.2.2 Disease Control Programmes ................................................................................................16
3.2.3 Reproductive, Maternal, Newborn, Child & Adolescent Health and Nutrition .................16
3.2.4 Social Welfare.........................................................................................................................17
3.3 Health Care Support Systems................................................................................. 18
3.3.1 Human Resources for Health ................................................................................................18
3.3.2 Essential Medicines and Health Products ............................................................................19
3.3.3 Capital Investment .................................................................................................................20
3.3.4 Monitoring and Evaluation....................................................................................................21
3.3.5 Health Financing.....................................................................................................................21
3.3.6 Leadership and Governance..................................................................................................23
4 Strategic Framework for the Health Sector.................................................................. 24
4.1 Introduction .......................................................................................................... 24
4.2 Mission and Vision of HSSP IV ................................................................................ 25
4.3 Overall and Specific Objectives of HSSP IV ............................................................. 25
5 Service Delivery .......................................................................................................... 30
5.1 Introduction .......................................................................................................... 30
5.2 Quality Assurance.................................................................................................. 30
5.3 Package of Intervention by Levels of Care .............................................................. 32
5.3.1 National Essential Health Care Intervention Package .........................................................32
5.3.2 Community Health .................................................................................................................33
5.3.3 Council Health Services .........................................................................................................34
5.3.4 Regional Referral Level ..........................................................................................................36

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 5.3.5 Zonal and National Level, including International referral .................................................37
Zonal Referral Hospitals ......................................................................................................................37
5.4 Health Service Provision by type of Service ............................................................ 38
5.4.1 Health Promotion...................................................................................................................38
5.4.2 Nutrition Services...................................................................................................................39
5.4.3 Reproductive, Maternal, Newborn, Child & Adolescent Health.........................................40
5.4.4 Communicable Diseases ........................................................................................................43
5.4.5 Non Communicable Diseases ................................................................................................47
5.5 Intersectoral Collaboration for Health ................................................................... 49
5.5.1 Water and Sanitation.............................................................................................................49
5.5.2 Occupational health...............................................................................................................49
5.5.3 General and Health Care Waste Management ....................................................................49
5.5.4 Port Health services ...............................................................................................................50
5.5.5 Road Safety.............................................................................................................................50
5.6 Emergency Preparedness and Response ................................................................ 50
5.7 Social Welfare service delivery .............................................................................. 51
5.7.1 General ...................................................................................................................................51
5.7.2 Policies and Strategies ...........................................................................................................52
5.7.3 Vulnerable groups ..................................................................................................................52
5.7.4 Juvenile Justice .......................................................................................................................53
5.7.5 Accountability mechanisms for child protection .................................................................53
6 Health Care Support Systems ...................................................................................... 54
6.1 Human Resources for Health and Social Welfare ................................................... 54
6.1.1 HRHSW planning and management .....................................................................................54
6.1.2 Distribution of staff ................................................................................................................54
6.1.3 Performance management ...................................................................................................55
6.1.4 Information and research......................................................................................................55
6.1.5 HRHSW development ............................................................................................................55
6.1.6 Nursing and Midwifery Services ...........................................................................................56
6.1.7 Professional Regulatory Councils..........................................................................................57
6.2 Essential Medicines and Health Products ............................................................... 57
6.2.1 Stewardship from the national level ....................................................................................58
6.2.2 Planning, Quantification, Costing, Procurement and Monitoring Supply Chain ...............58
6.2.3 Facility Planning, Quantification, Costing, Procurement and Utilisation of Medicines and
Health Products ...................................................................................................................................59
6.2.4 Research and Production ......................................................................................................59
6.2.5 Financing Medicines, Commodities, Devices and Supplies.................................................59
6.3 Infrastructure, Transport and Equipment .............................................................. 60
6.3.1 Infrastructure .........................................................................................................................60
6.3.2 Maintenance of equipment ..................................................................................................61
6.3.3 Transport and Ambulance Services ......................................................................................61
6.4 Monitoring and Evaluation Systems in Health and Social Welfare Sector ............... 61
6.4.1 HMIS........................................................................................................................................62
6.4.2 Other Data Systems ...............................................................................................................62
6.4.3 Operational Research and Surveys .......................................................................................63
6.4.4 Use of Data and Knowledge Management ..........................................................................63
6.5 Information and Communication Technology and e-Health ................................... 63
6.6 Health Financing .................................................................................................... 64
6.6.1 Health Financing Strategy 2015-2025 ..................................................................................64
6.6.2 Single National Health Insurance ..........................................................................................65
6.6.3 Minimum Benefit Package ....................................................................................................65
6.6.4 Financing Public Health Activities .........................................................................................65
6.6.5 Mobilising Resources for Health and Social Welfare ..........................................................66
6.6.6 Allocating resources for the health sector ...........................................................................66
6.7 Financial Management System .............................................................................. 66

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7 Management of Implementation and Governance ...................................................... 68
7.1 Governance in the Tanzanian Health and Social Welfare Sector Context................ 68
7.2 Specific Areas for Action on Implementation Management and Governance ......... 68
7.2.1 Decentralisation by Devolution ............................................................................................68
7.2.2 Social Accountability ..............................................................................................................69
7.2.3 Performance Management ...................................................................................................70
7.2.4 Partnership .............................................................................................................................70
7.3 Gender in Health ................................................................................................... 71
7.3.1 Gender Mainstreaming..........................................................................................................71
7.3.2 Gender Equity.........................................................................................................................72
7.3.3 Equity ......................................................................................................................................72
7.4 SWAp Co-ordination and Management ................................................................. 72
8 Resource Planning for HSSP IV .................................................................................... 76
8.1 Resource Needs..................................................................................................... 76
8.1.1 Methodology ..........................................................................................................................76
8.1.2 Total resource needs .............................................................................................................76
8.1.3 Costs of health services .........................................................................................................77
8.1.4 Costs of health systems .........................................................................................................78
8.2 Available Resources ............................................................................................... 78
8.3 Funding Gap .......................................................................................................... 80
9 HSSP IV Performance Assessment and Follow Up ........................................................ 81
9.1 Introduction .......................................................................................................... 81
9.2 Monitoring Health and Social Welfare Performance .............................................. 82
9.3 Monitoring HSSP IV implementation progress ....................................................... 83
9.3.1 BRN Monitoring......................................................................................................................83
9.3.2 Monitoring Achievements of Specific Objectives of the HSSP IV .......................................84
10 Assumptions and Risks ................................................................................................ 86
Annex 1 Background Documentation .................................................................................. 87
Annex 2 Detailed cost results, targets and fiscal space assumptions .................................... 95
Annex 3 Health Sector Performance Indicators.................................................................. 100
Annex 4 BRN Key Performance Indicators.......................................................................... 128
Annex 5 HSSP IV Specific Objectives Process Indicators ..................................................... 133

Figures
Figure 1 Building Blocks of the Health and Social Welfare System .............................................................2
Figure 2 BRN in Health ....................................................................................................................................8
Figure 3 Map of Tanzania with Regions and Zones.....................................................................................10
Figure 4 The health care pyramid in Tanzania (public and private equivalent)........................................12
Figure 5 Relations between levels of management in health and social services....................................14
Figure 6 Percentage of GOT budget 2006/07 - 2014/15 ............................................................................22
Figure 7 Total Health Expenditure by Financing Source and Financing Agent .........................................22
Figure 8 Strategic Framework for HSSP IV ...................................................................................................24
Figure 9 Health SWAp Coordination Structure and tentative linkages .....................................................73
Figure 10 Ambitious Scenario for Fiscal Space, with Higher Contributions for SNHI ...............................79
Figure 11 Comparison of Scenarios showing Impact of Innovative Financing and SNHI .........................79
Figure 12 Estimated Resources Needed vs. Available as Percentage of GDP ...........................................80
Figure 13 HSSP Performance Assessment and Follow-Up..........................................................................81
Figure 14 Annual progress monitoring using indicators from sets ............................................................85

Tables
Table 1 Health Indicators in Tanzania Mainland .........................................................................................11
Table 2 Current health service facilities (public and private).....................................................................13
Table 3 Health workforce supply in the base year 2014 ............................................................................19
Table 4 Criteria for Star Rating of Primary Health Facilities .......................................................................31

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Table 5 HSSP IV costs (TZS billions) by programme and health system component ................................76
Table 6 Selection of Health Sector Performance Indicators from HMIS (full list Annex 3) ......................82
Table 7 Top Line key indicators for BRN ......................................................................................................83
Table 8 Indicators for Measuring Performance of Specific Objectives......................................................84

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Acronyms
ADDO Accredited Drug Distribution Outlet
AFSRHR Adolescent Friendly Sexual and Reproductive Health Services
AHSPPR Annual Health Sector Performance Profile Report
AIDS Acquired Immuno-Deficiency Syndrome
ANC Antenatal Care
ART Antiretroviral Therapy
ASPM Annual Sector Planning Meeting
BEmOC Basic Emergency Obstetric Care
BEmONC Basic Emergency Obstetric and Newborn Care
BFC Basket Fund Committee
BRN Big Results Now
CBHP Community Based Health Programme
CBO Community Based Organisation
CBR Community Based Rehabilitation
CCHP Comprehensive Council Health Plan
CEmOC Comprehensive Emergency Obstetric Care
CEmONC Comprehensive Emergency Obstetric and Newborn Care
CFS Consolidated Fund Service
CHF Community Health Fund
CHMT Council Health Management Teams
CHSB Council Health Services Board
CHW Community Health Worker
CPD Continuing Professional Development
CPR Contraceptive Prevalence Rate
CPT Child Protection Team
CRP Community Rehabilitation Programme
CSC Community Score Card
CSO Civil Society Organization
CSSC Christian Social Services Commission
CPRP Community Prevention and Reintegration Programme
D-by-D Decentralisation by Devolution
DCF Development Cooperation Framework
DHIS District Health Information System
DHIS 2 District Health Information Software 2
D-HMIS District Health Management Information System
DHS Demographic and Health Surveys
DOTS Direct Observed Therapy Short Course
DP Development Partner
DPG-AIDS Development Partners Group AIDS
DPG-H Development Partners Group Health
DSW Department of Social Welfare
eMTCT Elimination of Mother To Child Transmission
EOP Emergency Operational Plan
FBO Faith-Based Organization
FP Family Planning
GBS General Budget Support
GBV Gender Based Violence
GDP Gross Domestic Product
GF Global Fund
GOT Government of Tanzania
HBF Health Basket Fund

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HBFC Health Basket Financing Committee
HFGC Health Facility Governing Committee
HFS Health Financing Strategy
HIS Health Information System
HIU Health Information Unit
HIV Human Immunodeficiency Virus
HMIS Health Management Information System [MTUHA]
HMT Hospital Management team
HR Human Resources
HRD Human Resources Development
HRH Human Resources for Health
HRHSW Human Recourses for Health and Social Welfare
HRHIS Human Resources for Health Information System
HRHSP Human Resource for Health Strategic Plan
HRIS Human Resources Information System
HRM Human Resources Management
HSR Health Sector Reforms
HSRS Health Sector Reforms Secretariat
HSSP III Health Sector Strategic Plan III (2009 – 2015)
HSSP IV Health Sector Strategic Plan IV (2015 – 2020)
HSSP Health Sector Strategic Plan
HSTC Health Sector Technical Committee
HSWG Health Sector Working Group
ICT Information Communication Technology
IDSR Integrated Disease Surveillance and Response
IEC Information, Education and Communication
IHI Ifakara Health Institute
IHR International Health Regulations
ILS Integrated Logistics System
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Rate
IPC Infection Prevention and Control
IPD In-Patient Department
ITN Insecticide Treated Nets
JAHSR Joint Annual Health Sector Review
KRA Key Result Area
KPI Key Performance Indicator
LGA Local Government Authority
LLIN Long Lasting Insecticidal Nets
LMIS Logistics Management Information System
LMU Logistics Management Unit
M&E Monitoring and Evaluation
MBP Minimum Benefit Package
MCT Medical Council of Tanganyika
MDA Mass Drug Administration
MNCH Maternal Newborn and Child Health
MDA Ministries, Departments, Agencies
MDA Mass Drug Administration
MDGs Millennium Development Goal(s)
MDR TB Multi Drug Resistant Tuberculosis
MDU Ministerial Delivery Unit
MKUKUTA Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania [NSGRP]
MMAM Mpango wa Maendeleo ya Afya ya Msingi [PHSDP]
MNCH Maternal, Newborn and Child Health
MOCS&T Ministry of Communication, Science and Technology
MOEVT Ministry of Education and Vocational Training
MOF Ministry of Finance

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MOHSW Ministry of Health and Social Welfare
MSD Medical Stores Department
MTC Medicines Therapeutics Committee
MTEF Medium Term Expenditure Framework
MTR Mid-Term Review
MTSP Medium Term Strategic Plan
MTUHA Mfumo wa Takwimu wa Uendeshaji wa Huduma za Afya [HMIS]
MUCHS Muhimbili University College of Health Sciences
MVC Most Vulnerable Children
MVCC Most Vulnerable Children Committee
MUHAS Muhimbili University of Health and Allied Sciences
NACP National AIDS Control Programme
NACTE National Accreditation Council for Technical Education
NAO National Audit Office
NBS National Bureau of Statistics
NBTS National Blood Transfusion Service
NCD Non Communicable Diseases
NEHCIP National Essential Health Care Interventions Package
NGO Non-Governmental Organization
NHA National Health Accounts
NHIF National Health Insurance Fund
NIMR National Institute for Medical Research
NKRA National Key Result Area
NMCP National Malaria Control Programme
NMP National Medicines Policy
NSGRP National Strategy for Growth and Reduction of Poverty[MKUKUTA]
NSHP National School Health Programme
NTD Neglected Tropical Diseases
NTLP National Tuberculosis and Leprosy Programme
OPD Outpatient department
OPRAS Open Performance Review and Appraisal System
OPP Out-of Pocket Payment
OVC Orphans and Vulnerable Children
PDB Presidential Delivery Bureau
PER Public Expenditure Review
PFM Public Finance Management
PHA Public Health Act
PHC Primary Health Care
PHDR Poverty and Human Development Report
PHSDP Primary Health Services Development Programme [MMAM]
PMO-RALG Prime Minister’s Office – Regional Administration & Local Government
PMTCT Prevention of Mother to Child Transmission
PLHIV People living with HIV
PNC Post-natal Clinic
PO-PSM President’s Office – Public Service Management
POW Programme of Work
PPHF Public Private Health Forum
PPP Public Private Partnership
PSRP Public Service Reforms Programme
PWDs People With Disabilities
QA Quality Assurance
QI Quality Improvement
QIT Quality Improvement Team
RAS Regional Administrative Secretary
RBF Results Based Financing
RCH Reproductive and Child Health
RHHSB Regional Hospital Health Services Board

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RHMT Regional Health Management Team
RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health
RRH Regional Referral Hospital
RAS Regional Administrative Secretariat
SA Service Agreement
SARA Service Availability and Readiness Assessment
SAVVY Sample Vital registration with Verbal Autopsy
SCD Sickle Cell Disease
SDG Sustainable Development Goal
SMC Senior Management Committee
SNHI Single National Health Insurer
SOPs Standard Operating Procedures
SPD Sentinel Panel of Districts
STEPS WHO Stepwise approach to Surveillance for Chronic Diseases
STIs Sexually Transmitted Infections
SWAp Sector-Wide Approach
SWCA Stepwise Certification Towards Accreditation
SWIS Social Welfare Information System
SWO Social Welfare Officer
TACAIDS Tanzania Commission for AIDS
TASAF Tanzanian Social Action Fund
TB Tuberculosis
TB/L Tuberculosis and Leprosy
TC Technical Committee SWAp
TDHS Tanzania Demographic and Health Survey
TFDA Tanzania Food and Drug Authority
TFNC Tanzania Food and Nutrition Centre
THMIS Tanzania HIV Malaria Indicator Survey
TIKA Tiba Kwa Kadi (CHF in urban areas)
TNCM Tanzania National Coordinating Mechanism
TOR Terms of Reference
TPEHI Tanzania Package of Essential Health Interventions
TPHA Tanzania Public Health Association
TPRI Tropical Pesticides and Research Institute
TQIF Tanzania Quality Improvement Framework
TSH Tanzanian Shilling
TWG Technical Working Group
TZS Tanzania shillings
U5MR Under-five Mortality Ratio
VMMC Voluntary Medical Male Circumcision
VRS Vital Registration System
WASH Water, Sanitation and Hygiene
WDC Ward Development Committee
WHO World Health Organization
ZHRC Zonal Health Resource Centre

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Key Messages of HSSP IV

Background

The Health Sector Strategic Plan 2015 – 2020 (HSSP IV) was conceived in a participatory
process under the leadership of the Ministry of Health and Social Welfare (MOHSW), with
inputs from Governmental, Non-Governmental and Private Sector Partners, with
contributions from Ministries, Departments and Agencies (MDAs), especially the Prime
Minister’s Office for Regional Administration and Local Government (PMO-RALG) and from
Development Partners (DPs). For the first time a thorough effort was made to make reliable
cost estimates, prioritise interventions based on available resources and define realistic
targets for the health and social welfare sector.

Tanzania Development Vision 2025 (Vision 2025) is a document providing direction and
philosophy for long-term development. The Government Health Policy aims to improve the
health of all Tanzanians, especially those at risk, and to increase the life expectancy, by
providing health services that meet the needs of the population. The health and social
welfare sector programme of Big Results Now (BRN) 2015 - 2018, the national programme
for accelerating development, is fully incorporated in this strategic plan. The Sustainable
Development Goals (SDGs) as successors to the Millennium Development Goals (MDGs)
provided important input to the planning process of this HSSP IV. Achievement of SDGs and
the unfinished business of the MDGs have been considered in formulating HSSP IV.

The health status of the population is slowly improving and life expectancy is increasing. The
trends in Child Mortality and Infant Mortality are downwards, and Tanzania is expected to
meet the targets of the MDGs in 2015. The trends in Neonatal Mortality and Maternal
Mortality are also downwards, but less, and not meeting MDG targets.
While Disease Control Programmes in HIV/AIDS, Malaria and Tuberculosis are quite
successful in early detection and treatment, there is room for improvement in the area of
prevention. Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCAH) in
general is performing less effectively than control of communicable diseases. Overall service
utilisation is not reaching the required level. Non-communicable diseases are increasing and
unhealthy life styles are becoming more prominent. However, the country does not yet have
the capacity for an adequate response.

Health and social welfare services are provided from the grassroots level up through higher
levels of care, beginning with community health care, dispensaries and health centres, and
proceeding through first level hospitals, regional referral hospitals and zonal and national
hospitals, all providing increasingly sophisticated and well-defined services. Due to
constraints in human resources and supplies of medicines and health products, not all
primary health services are of sufficient quality. In certain geographical areas, populations
still live far away from health services. This is especially problematic in terms of maternal
and newborn care. The referral system does not always function as required, sometimes due
to a lack of adequate transport to the next level of care or due to an inability at the referral
level to provide adequate services.

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Strategic Objectives

The overall objective of HSSP IV is to reach all households with essential health and social
welfare services, meeting, as much as possible, the expectations of the population, adhering
to objective quality standards, and applying evidence-informed interventions through
efficient channels of service delivery.

Strategic Objective 1: The health and social services sector will achieve objectively
measurable quality improvement of primary health care services, delivering a package of
essential services in communities and health facilities.

HSSP IV proposes a multilevel Health Systems Strengthening (HSS) programme, with a focus
on quality of care in health institutions from the primary care to the tertiary and national
levels. Quality Improvement will be enhanced by the BRN activities under four Key Result
Areas. The health and social welfare sector will take the BRN approach further, to all regions
in the country and beyond 2018 (when the BRN programme ends).

Health facilities will ensure that essential services are provided. The MOHSW will further
refine the National Essential Health Care Intervention Package (NEHCIP) as well as a
Minimum Benefit Package for the Single National Health Insurance. The country will
strengthen emergency preparedness and response to disasters.

The Star Rating and Improvement system will set objective criteria for minimum standards
to be achieved. The development of a stepwise certification and accreditation system and
linkage of quality to performance and insurance payments will stimulate the health facilities
to improve.

Stepping up recruitment, retention and (re)distribution of Human Resources for Health

(HRH) will ensure adequate staffing of all primary health care facilities in all Regions. Council
Health Management Teams (CHMTs) and Regional Health Management Teams (RHMTs) will
improve coaching, mentoring and supervision.

Performance management systems will motivate health staff and social welfare workers to
provide quality services. There will be measures to ensure accountability, deterring pilferage
and corruption. Cases of corruption will be dealt with immediately. Quality will also improve
through an adequate supply of medicines and health products and through refurbishment
and equipping of health facilities.

Maternal and newborn services will reach under-served areas and under-served groups and
will meet the quality standards for primary and referral care. Basic and Emergency Obstetric
and Newborn Care will be available throughout the country. This will result in considerable
reduction in both maternal and neonatal mortality. Adolescent girls and young women are
at a higher risk of HIV infection and will receive adequate care. Increased availability of safe
blood will reduce maternal mortality as well as mortality due to severe accidents.

The country will maintain the high level of quality of HIV and AIDS programmes, prevention
and control of malaria, as well as early detection and treatment of tuberculosis and leprosy.
Non-communicable diseases (NCDs) put an increasing burden on the health sector, with
quickly increasing demands for services, especially for cardio-vascular diseases, diabetes and
cancer. The health facilities will as much as possible respond to this demand and gradually
step up the diagnostic and therapeutic capacities for NCDs.

xiii
Health facilities will maintain high levels of vaccination coverage; improvements in access to
addition geographical areas will be provided where needed, and new types of vaccinations
will be introduced as they are developed and approved. Curative services for children will be
provided in an integrated way in all health facilities at the appropriate level, including
services for malnourished children. The country will step up nutrition interventions to bring
down the numbers of stunting in children under-5 years of age, in the course of promoting
optimal nutrition and control of emerging obesity in specific population groups.

In the area of social welfare, quality will be maintained through integration of social welfare
and health services at all levels and through the creation of an inspectorate and
development of a monitoring framework. Social welfare services will focus on child
wellbeing and on family and household security for better living. Vulnerable groups, e.g.,
people living with disabilities, will be assisted to participate optimally in society.

Prevention of communicable and non-communicable diseases will receive high priority.

Improved facility and service quality will generate the trust of the population and create
demand for the Single National Health Insurance. In addition, this will stimulate people to
take ownership of the health services in their communities.

There will be emphasis on applying a human rights based approach in health programmes
and clients’ rights by revitalising the Client’s Charter. In the area of social welfare, the rights
of vulnerable groups (persons with disabilities, orphans, elderly, female headed households,
persons with chronic diseases, homeless, etc.) will be protected. The MOHSW and partners
will engage in a public awareness campaign to sensitise the population about their rights and
responsibilities and will reach all households in this effort.

Strategic Objective 2: The health and social welfare sector will improve equitable access to
services in the country by focusing on geographic areas with higher disease burdens and by
focusing on vulnerable groups in the population with higher risks.

Priority setting based on epidemiological analysis will become standard, targeting under-
served populations and vulnerable groups, and responding to high priority health needs.

Improving community health and social welfare services by professional Community Health
Workers in integrated health programmes will include a Social Welfare Attendant that will
attend to social welfare issues in community settings, including under-served populations
living far from health facilities. Further integration of social welfare and health services and
closer collaboration with other ministries, agencies and non-governmental organisations will
make social welfare services more accessible to people in need of assistance.

Gender equity will receive increased attention in concrete measures, e.g., focus on
prevention of HIV among adolescent girls, addressing violence against women. Also, in
committees and boards, equal representation of women will be prioritised.

Strategic Objective 3: The health and social welfare sector will achieve active community
partnership through intensified interactions with the population for improvement of health
and social wellbeing.

Partnership with community based organisations will contribute to revitalising primary

health care and community based social welfare services. Strengthening communities will
improve health literacy and health seeking behaviors of the population. More community

xiv
participation in the management of health facilities will contribute to regaining trust in the
health care system. A system of social accountability will be put in place to strengthen
bottom-up planning and transparent reporting to Boards and Committees.

The health and social welfare sector will engage with the population in modern interactive
communication via e-health platforms to establish partnerships between the government
and citizens.

The new health care financing strategy, which promotes the development of a single
national health insurance with effective risk-pooling and social protection, will increase the
affordability of health care, also for the poorer citizens, and will enhance sustainable
development of the health care sector.

Strategic Objective 4: The health and social welfare sector will achieve a higher rate of
return on investment by applying modern management methods and engaging in
innovative partnerships.

Improvement of health and social welfare services can be realised through increased
effectiveness and efficiency. Improving the technical competency of health workers and
ensuring adherence to quality standards will increase the overall effectiveness of services.
Further decentralisation of responsibilities to the health facility level will enhance efficiency.
The sector will strengthen the evidence base for interventions through robust Monitoring
and Evaluation (M&E) systems and operational research, including monitoring adherence to
quality standards. Better use of these information systems will improve efficient
communication and decision-making concerning the utilisation of scarce resources.
Improvement of the logistics systems for the supply of medicines and health products and
strengthened management of the Medical Stores Department is a high priority.

The Health Financing Strategy (HFS) includes a key innovation, the concept of a legally
established Single National Health Insurer (SNHI), which will increasingly generate and pool
resources for the sector while protecting the poor and vulnerable groups. Other innovative
ways of resource mobilisation including sin taxes, levies and trust funds will be considered as
a part of the strategy.

In the implementation of the HFS, partnership in the health and social welfare sector is
crucial, at all levels. Public and private providers will work together in the delivery of health
services, with the intention to provide room for innovative approaches (e.g., new
contracting arrangements) in service delivery and for the promotion of private sector
engagement.

In health care financing, opportunities for public private partnership will be created, which
allow the business community to collaborate with public as well as private partners in the
health sector. The government’s role will be to facilitate these investments in the health
sector.

Recognising that the country is still largely relying on external financial and technical support
for health and social welfare services, the MOHSW will continue to uphold the Sector Wide
Approach in the health and social welfare sector, strengthening financing of one sector plan,
country level partnerships and international collaboration, while addressing donor
dependency through financial sustainability plans and exit strategies.

xv
Strategic Objective 5: To address the social determinants of health, the health and social
welfare sector will collaborate with other sectors, and advocate for the inclusion of health
promoting and health protecting measures in other sectors’ policies and strategies.

The sector will mobilise non-governmental and private partners to promote health and
wellbeing through their strategies. Improved health and social wellbeing of the nation are
essential towards realising the Nation’s Vision 2025. Investing in health is therefore a
necessity for the country to meet its development objectives.

The health and welfare sector alone cannot achieve optimal health and wellbeing for all
individuals. Social determinants of health and wellbeing, like nutrition, housing, safe water,
safe and hygienic environment, individual behaviours and security are crucial. For addressing
the social determinants of health, economic development, housing, education, roads and
communication are of great importance. One approach for addressing social determinants of
health is for the MOHSW to advocate for health impact assessments prior to major
developmental initiatives in other sectors.

Social welfare interventions focus on achieving acceptable standards of social wellbeing and
protection for vulnerable groups in society, and enable those groups to fully participate in
society and contribute to development of the country. The social welfare sector interacts
with many other sectors and areas, like economic development, education, or food security.
Like health, social welfare has to be integrated in other sectoral policies.

Advocating for health considerations in all policies is not only a responsibility for the
MOHSW, but also for local and regional health and social welfare organisations in the
decentralised government systems.

Governance and Implementation

The management of health services takes place within the legal context of the Government
of Tanzania, which extends beyond the health sector. The MOHSW plays a stewardship role
in the health sector while PMO-RALG plays a prominent role in implementation. The
Decentralisation by Devolution (D-by-D) policy will continue to be applied down to the level
of the health facilities. There are also many private and non-governmental players in the
sector, who will be invited to play a bigger role in service provision. Citizens and
communities also play a critical role in the health sector. Social accountability interventions
will give them a bigger voice and more responsibilities. The government encourages shared
policies and programs among sectors, with common participants working together beyond
health sector specific interventions, towards common goals.

The successful Sector Wide Approach (SWAp) will be streamlined to serve joint planning,
monitoring, and implementation of all stakeholders, especially the DPs who contribute to
financing the health and social welfare sector.

Financing HSSP IV

The five-year cost of the HSSP IV is estimated to be TZS 21,945 billion. Costs increase each
year from TZS 4,013 billion in 2015/2016 to TZS 4,859 billion in 2019/2020. This is equivalent
to a stable per capita expenditure of around USD $42. Increases in costs keep pace with
population increases. Approximately half of the HSSP IV financial resource requirements are
for health services, which include commodity and programme management costs. Two
disease control programmes (HIV/AIDS and NCDs, including mental health) account for

xvi
about half of total health service costs. These costs reflect the MOHSW’s prioritised scale-up
of health interventions, given the fiscal space and health system constraints.

Several scenarios for income generation for the health sector show that, even in a
pessimistic scenario, income will be around 2,600 billion Tanzania Shillings annually (TZS). In
the most optimistic scenario, income will rise from 2,600 billion TZS in 2015/16 to 3,650 TZS
in 2016/17 and 2018/19, and slowly decrease to 3,250 TSZ in 2020/21.

In all scenarios there will be a funding gap, which can vary from 500 billion TZS to 2,500
billion annually, depending on realised income over the years. This has to be covered by
additional resources mobilisation, or, if this is not feasible, the targets defined in this HSSP IV
have to be adjusted.

Monitoring the HSSP IV implementation

The MOHSW has defined a framework for HSSP IV Performance Assessment and Follow-Up,
which includes a set of national HSSP IV indicators (see below) covering all areas of
population health, service delivery outputs, support systems performance, as well as
governance and financial areas. Furthermore, the M&E framework incorporates the Key
Performance Indicators as formulated for the BRN National Key Result Area for Health.

Finally, the M&E framework contains a number of more qualitative indicators which
monitoring implementation activities of HSSP IV strategies. M&E will take place at regular
intervals, with an emphasis on measuring annual health sector performance, drawing from
the three indicator sets. The Joint Annual Health Sector Review (JAHSR) will have the
necessary inputs for strategic decisions for improvement on the performance of the health
and social welfare sector.

xvii
1 Introduction
Tanzania has a long-standing history of participatory strategic planning in the health and
social welfare sector, under the leadership of the Ministry of Health and Social Welfare
(MOHSW). Over the past 10 years, the Health Sector Strategic Plans (HSSP) have been
guiding the annual Comprehensive Council Health Plans (CCHP) of the Local Government
Authorities (LGA) and the Strategic Plans of Departments, Agencies and Programmes in the
health and social welfare sector. The HSSPs have oriented the Sector Wide Approach (SWAp)
involving other Ministries, especially the Prime Minister’s Office – Regional Administration
and Local Government (PMO-RALG), national non-governmental and private partners and
the international Development Partners (DPs).

The planning process has always been guided by the development objectives of the
Government of Tanzania (GOT), through analysis of the needs of the population and the
identification of bottlenecks in services provided, as well as international agreed health
goals, especially the Millennium Development Goals (MDGs). Over the years, the plans
became more complete, with better description of available resources and improved
monitoring methodology. The planning process has been increasingly inclusive, involving
many stakeholders in the health and social welfare sector from different levels and different
backgrounds.

The Health Sector Strategic Plan 2015 – 2020 (HSSP IV) was conceived in a participatory
process, guided by the HSSP IV Steering Committee chaired by the Permanent Secretary of
the MOHSW and co-chaired by the Deputy Permanent Secretary Health of the PMO-RALG.
Representatives from Ministries, Departments and Agencies (MDAs), Non-Governmental
Organisations (NGOs) and the Private Sector, as well as Development Partners (DPs)
participated in the Steering Committee. A Task Force consisting of members of the Health
Resources Secretariat within the Department of Policy and Planning (DPP) and
representatives from various stakeholders managed the day-to-day process. In the process,
two work streams, which initially were running parallel, were combined: the technical
priority setting on the one hand and the costing of interventions and estimation of the fiscal
space on the other hand.

The process started with inputs from the fourteen Technical Working Groups (TWGs) in the
health and social welfare sector to produce the Zero Draft HSSP IV, reflecting their priorities
and planned actions. This draft was shared and comments were discussed in a workshop in
January 2015, where overarching topics and priorities were agreed. Draft One was
disseminated widely and many stakeholders gave their inputs to the proposed strategies:
health care professionals, interest groups, governmental and non-governmental
organisations, departments, agencies, development partners and international
organisations. Thereafter a revised draft was produced.

In the final phase of formulation, technical strategic priorities were matched with the
financial projections. Those were thoroughly discussed in two meetings with all stakeholders
in April 2015 resulting in an evidence-based, realistic HSSP IV, guiding development in the
health sector in the coming five years.
The health and social welfare sector programme of Big Results Now 2015 - 2018, the
national programme for accelerating development, has been fully incorporated in this
strategic plan.

HSSP IV shortly describes the relevant Government Policies and Strategies (Section 2).
Section 3 provides an overview of the current status of the health and social welfare sector.
The strategic framework with overall and specific objectives is found in Section 4. The
strategies are presented according to the (modified) system building blocks, as frequently
used in publications of the World Health Organisation (see figure 1 below). The description
of the planned activities starts with client services (Section 5) and continues with support
services (Section 6). Section 7 explains the implementation modalities and governance
arrangements and Section 8 discusses the fiscal space available for the health and social
welfare sector. The framework of measuring and assessing the health and social welfare
sector and the implementation of HSSP IV is discussed in Section 9. Risks and risk mitigation
are presented in Section 10.

Annex 1 shows the list of laws and regulations and background strategic documents
concerning specific areas. Annex 2 shows the background to the resources calculations
presented in Section 8. Annex 3, 4 and 5 provide the indicators for monitoring of the health
sector and HSSP IV implementation as discussed in Section 9.

Figure 1 Building Blocks of the Health and Social Welfare System

2
2 Government Policies
2.1 General Policy Framework

In Tanzania a coherent system of government policies, legislation, strategies and

programmes exists to give direction to development. Consistency between general and
sectoral policies is improving. The pace of policy implementation has been varied in
application and enforcement.

2.1.1 Tanzania Development Vision 2025

Tanzania Development Vision 2025 (Vision 2025) is a document providing direction and a
philosophy for long-term development. By 2025, Tanzania wants to achieve a high quality of
livelihood for its citizens, peace, stability and unity, good governance, a well-educated
society, and a competitive economy capable of producing sustainable growth and shared
benefits by 2025.

The Vision 2025 document identifies health as one of the priority sectors contributing to a
higher-quality livelihood for all Tanzanians. This will be attained through strategies, which
will ensure realisation of the following health service goals:
 Access to quality primary health care for all;
 Access to quality reproductive health services for all individuals of appropriate ages;
 Reduction in infant and maternal mortality rates by three-quarters of levels in 1998;
 Universal access to clean and safe water and sanitation;
 Life expectancy comparable to the level attained by typical middle-income countries;
 Food self-sufficiency and food security; and
 Gender equality and empowerment of women.

2.1.2 MKUKUTA and Five Years’ Development Plan 2011/12-2015/16

The National Strategy for Growth and Reduction of Poverty, known in Kiswahili as the
MKUKUTA, represents Tanzania’s commitment to the achievement of the MDGs. MKUKUTA
II covers the period 2010/11 – 2014/15. It focuses on growth, social well-being and
governance, and is a framework for all government development efforts and for mobilising
resources.

The MKUKUTA aims to foster greater collaboration among all sectors and stakeholders. It
has mainstreamed crosscutting issues (gender, environment, HIV/AIDS, human rights,
disability, children, youth, elderly, employment and settlements) into all sector strategies.
All sectors are involved in a collaborative effort rather than segmented into separate
activities. Therefore, this document is of crucial importance for the MOHSW strategies.

The Five Years’ Development Plan (FYDP I) 2011/12 – 2015/16 aims to mobilise Tanzania’s
resource potential in order to fast-track the provision of the basic conditions for broad-
based and pro-poor growth. Five crucial elements will generate this growth momentum: (i)
large investments in energy and transport infrastructure, (ii) strategic investments to expand
productive sectors: high value crops and production of food for self-sufficiency and exports;
tapping the large natural gas and phosphate deposits; development of Special Economic

3
Zones (SEZs) to foster economic growth; (iii) enhancing skills development, (iv) drastically
improving the business environment, and (v) institutional reforms for an effective
implementation, monitoring and evaluation of the Plan.

The FYDP I sets as goals for the health sector:

 Increase accessibility to health services, based on equity and gender-balanced needs
 Improve quality of health services
 Strengthen management of the health system
 Strengthen management of policies and regulations of health services
 Enhance human resource development for health and social welfare

2.1.3 Big Results Now

In 2014, the National Key Result Area (NKRA) in health care was introduced in the Big Results
Now approach, to join other NKRAs that were adopted by the Government of Tanzania (GOT)
in 2013, in order to enhance the implementation of the Five Years’ Development Plan
2011/12 – 2015/16 and the Vision 2025. The health care NKRA is the eighth NKRA under the
Big Results Now programme.

The BRN approach or methodology emphasises prioritisation, focused planning, and efficient
resource management. The BRN approach aims to instil a sense of accountability, and
discipline in implementation through focused monitoring and evaluation. The Presidential
Delivery Bureau (PDB) manages and directs the implementation of the NKRAs and monitors
the performance of the outcomes. The PDB also supports the Ministerial Delivery Units
(MDU) at ministerial levels to implement and monitor priority initiatives. The BRN focus in
the Health Sector is elaborated in section 2.2.3.

2.2 Health Sector Policy Framework

2.2.1 Health Policy

The MOHSW revised the 1990 National Health Policy in 2003 and 2007. On-going socio-
economic changes, new government directives, emerging and re-emerging diseases and
advances in science and technology have necessitated these policy updates. The policy
outlines achievements and challenges facing the health sector. The Government aims to
improve the health of all Tanzanians, especially those at risk, and to increase the life
expectancy, by providing health services that meet the needs of the population.

In summary, specifically the Government aims to:

1. Reduce morbidity and mortality in order to increase the life expectancy of all Tanzanians
by providing quality health care as needed;
2. Ensure that basic health services are available and accessible for all people;
3. Prevent and control communicable diseases, especially AIDS, Malaria, Tuberculosis, and
non-communicable diseases resulting from mismanagement of chemicals, poor
nutrition, environmental and working conditions.
4. Sensitise the citizens about preventable diseases and measure to improve health;
5. Create awareness on the part of the individual citizen to his/her responsibility on his/her
health and the health of their family;

4
6. Build partnership between public sector MDAs, private sector (including traditional and
alternative medicine providers) actors, religious institutions, civil society and community
based organizations in the provision of health services;
7. Plan, train, and increase the number of competent health staff for all levels of health
care;
8. Identify needs for health services in communities; construct and maintain health
infrastructure and medical equipment; and
9. Review, evaluate and produce health policy, guidelines, laws and standards for provision
of health services.

2.2.2 MMAM

In 2007 the MOHSW developed the Primary Health Care Services Development Programme,
better known as the MMAM 2007–2017 (MOHSW 2007). The objective of MMAM is to
accelerate the provision of primary health care services for all by 2017, while the remaining
five years of the programme would focus on consolidation of achievements. The main areas
are strengthening the health systems, rehabilitation, human resource development, the
referral system, increasing health sector financing and improving the provision of medicines,
health care waste management, sanitation, equipment and supplies. The MOHSW supervise
implementation of this plan in collaboration with other government administrative
structures, which include PMO-RALG, Local Government Authorities (LGAs) and Ward
Development Committees.

2.2.3 National Key Result Area in Healthcare (BRN)

In 2014, the National Key Result Area in healthcare was introduced and four broad outcomes
(Key Result Areas, KRAs) were identified with twenty-two initiatives to be implemented for
three years, from 2015/16 to 2017/18, in order to achieve the set targets and goals. These
initiatives are to be implemented in collaboration with the MOHSW, PMO-RALG, PO-PSM
and Medical Stores Department (MSD). The four key results areas that were formulated in
the Health and Social Welfare sector include:

1. Human Resources for Health (HRH) interventions aim to attain 100% balanced
distribution of skilled health workers at the primary level in thirteen underserved
regions by 2017/18. There are six distinctive initiatives that include: prioritise allocation
of employment permits to regions with critical shortage of skilled HRH, provision of
skilled HRH through public private partnership and private sector engagement, and
redistribution of health workers within regions. Also, optimising the pool of new
recruits, empowering the LGAs in Human Resource Management and synchronising the
recruitment process at the central level are among the goals.

2. Health Commodities targets focus on ensuring 100% stock availability of essential

medicines in all primary health facilities in the country, through the implementation of
the following six initiatives: (1) improved governance and accountability to the health
commodity supply chain, (2) eliminating frequent stock outs and pilferages, (3)
strengthening the management of MSD’s working capital and complementing MSD in
the procurement and distribution of medicines through engagement with the private
sector, and therefore improving accountability. The other initiatives include: (4)
introducing an ICT mobile application platform, (5) expanding the SMS reporting system

5
 and (6) scaling up Total Quality Management initiatives to the primary facility level using
the 5S-KAIZEN approach.

3. Health facility performance management improvement goals include achieving 80% of

primary health facilities at the 3-stars and above rating by 2017/18 in twelve identified
priority regions. This is to be achieved through four initiatives: (1) assess, rate and
develop specific facility performance improvement plans for health facilities below 3-
stars at primary level with introduction of the Star Rating system of certification; (2)
increase social accountability at facility and community level, (3) introduce performance
targets and contracts, and (4) implement decentralisation of fiscal management from
council level to health facility level.

4. Reproductive Maternal Neonatal Adolescent and Child Health (RMNCAH) services

target the achievement of 20% reduction in maternal and neonatal mortality rates in
five identified priority regions by 2017/18. The following six initiatives will be
implemented to achieve the stated goals: (1) mobilise Community Health Workers
(CHWs) to improve RMNCAH services, (2) use of m-Health (SMS) and Maternal CHW App
(Internet) through PPP, (3) Expansion of Comprehensive Emergency Obstetric and
Neonatal Care (CEmONC) and (4) Basic Emergency Obstetric and Neonatal Care
(BEmONC) services, (5) construction of Satellite Blood Bank facilities at regional level and
(6) development of integrated mass media campaigns through PPP. The RMNCAH
services will be provided through a continuum of care from family planning, antenatal
care, labour and delivery and care during the postnatal period for both mother and the
newborn.

Across the four KRAs there will be baseline assessments to get accurate starting information
on data for target setting and assessment of performance. Baseline assessments will be
conducted by the MOHSW with collaboration from the respective LGAs. At all levels, there
will be weekly reporting and monitoring of key performance indicators from facilities to the
MOHSW and to the President’s Office. Data for quarterly monitoring of the progress of the
NKRAs and other initiatives will be readily available for utilization in the HMIS and DHIS2.

Of the twenty-two initiatives, PMO-RALG will implement the following nine initiatives:
 Redistribution of health care workers within regions;
 Empowering LGAs in Human Resource Management;
 Increase of social accountability interventions at facility and community level;
 Introduction of performance targets and contracts, including strengthening of OPRAS;
 Implementation of fiscal decentralisation by devolution, from Council level to health
facility level;
 Improvement of governance and accountability in the health commodity supply chain,
to eliminate frequent stock outs and pilferages;
 Mobilisation of CHWs to improve RMNCAH;
 Expansion of CEmONC services; and
 Expansion of BEmONC services.

The MOHSW will facilitate implementation of the following initiatives, where needed, in
collaboration with PMORALG:

6
 Prescribe the characteristic of the new recruits through reinforcing the bonding policy
and introduce compulsory attachments;
 Advice on provision of skilled workers through PPP/Private engagement;
 Facilitate the implementation of baseline assessments for all initiatives, including
baseline assessment and Star Rating of health facilities and provision of specific
improvement facility interventions;
 Establish national guidelines to SMS reporting system for commodities and general
quality of services;
 Establish national guidelines for the use of m-Health (SMS) and Maternal CHW App
through PPP to facilitate utilisation of RMNCAH services;
 Coordinate training for CHWs, BEmONC and CEmONC staffs at primary facility level;
 Coordinate training for scaling up 5S-KAIZEN TQM initiatives to primary facility level;
 Coordinate the construction of Satellite Blood Bank facilities at regional level; and
 Coordinate the development of integrated Mass Media Campaigns through PPP.

PO-PSM will implement two initiatives:

 Prioritisation of allocation of employment permits to underserved regions with critical
shortage; and
 Synchronisation of recruitment process at the central level.

The MSD will implement the following two initiatives:

 Strengthening management of MSD working capital; and
 Engagement with the private sector to complement MSD in proc urement and
distribution of medicines.

The RCHS section in particular will in close coordination with PMO-RALG facilitate training
and mentoring to CHWs and health care workers as well as to their supervisors, while
mobilization of the CHWs at community level will be implemented by the LGA in PMO-RALG.

The BRN activities are summarised in figure 2 below.

7
Figure 2 BRN in Health
Overview of BRN Healthcare System
Healthy Tanzanians
Reproductive & Child Non-communicable
Infectious Diseases Others
Health Diseases & Injuries

Human Resources for Health Health Facilities Health Commodities

Prioritise utilisation of Improving health

employment permits Star-Rating commodities supply chain
System

Provide skilled HRH

Strengthen management of
through PPP/Private
MSD working capital
sector engagement

Fiscal decentralisation to
Redistribution of health facility level complement MSD in procurement &
health workers distribution of medicines by engaging
within regions private sector

Synchronize
Optimising Empowering Social Performance ICT mobile SMS Scale up 5S-
recruitment
the pool of LGAs in HR accounta- targets & application reporting Kaizen TQM
process at
new recruits management bility contracts platform system initiatives
central level

Special focus: RMNCH

Regional Satellite Blood bank

CEmONC Community Health Workers
facilities supporting CEmONC

Develop integrated 360° mass media

mHealth (SMS) and Maternal CHW
BEmONC campaign that can be multi
application through PPP 6
sponsored through PPP

The BRN has identified priority regions for actions, based on a thorough situation analysis.
Most underserved or under-performing regions will be targeted first. BRN activities
constitute the core of HSSP IV and are fully integrated in the HSSP IV. The 22 initiatives listed
above will continue beyond June 2018. Similar achievements as planned for BRN target
regions will be achieved or surpassed countrywide by the end of the HSSP IV period.

2.3 Health and Social Welfare Legislation, Policies and Strategies

The MOHSW is mandated to prepare for Government health and social welfare legislation
and policies, as well as oversee their implementation through sector wide monitoring and
evaluation. The Ministry and its Departments and Agencies produce strategies, work plans,
guidelines and other documents elaborating the policy documents and legislation.
PMORALG oversees implementation of health services by LGAs. The MOHSW monitor that
all Tanzanians access quality health and social welfare services.

The existing health and social welfare sector legislation is mainly divided into:
 Public Health legislation which is for the control of epidemics, infectious diseases and
environmental health protection;
 Health professional legislation which governs the practice and conduct of health
professions and professionals such as doctors, dental practitioners, pharmacists, nurses
and allied health personnel;
 Legislation, which establishes autonomous health and social welfare institutions for a
particular need, such as National Institute for Medical Research, National and Special
Hospitals, Institute of Social Work, etc.;

8
 Health financing legislation, which seeks to provide alternative health financing
mechanism with the aim of complementing government efforts to finance health
services in the country; and
 Legislation, which guarantees the rights of vulnerable groups like persons with
disabilities, children, destitutes, etc. which the Minister responsible for social welfare is
empowered to make Regulations for the better implementation of the law.

These laws and its regulations need to be effectively implemented in order to accomplish
the intended objectives of their enactment. Furthermore, due to a number of socio-
economic changes, policy and political changes, enactment and review of the existing health
and social welfare legislation is an on-going undertaking. In annex 1 an overview is provided
of relevant government documents informing the HSSP IV, arranged according to the
building blocks of the health and social welfare sector.

9
3 Health and Social Welfare at a Glance
3.1 Demography, Statistics and Structures of Health and Social Services
3.1.1 Tanzania Geography and Population

The United Republic of Tanzania (comprising of Tanzania mainland and the semi-
autonomous Islands of Zanzibar) is the largest country in East Africa covering 947,300 square
kilometres. Tanzania Mainland has 27 administrative Regions, 133 Districts and 162 Councils.
Each Council is divided into Divisions, which in turn are composed of 3-4 Wards (with 5-7
villages each). The Local Governments (LGs or Councils) are the most important
administrative and implementation units for public services.

Figure 3 Map of Tanzania with Regions and Zones

According to the latest Population and Housing Census of 2012, Tanzania Mainland had a
population of 43,625,354 comprised of 21,239,313 males and 22,386,041 females with an
average annual growth rate of 2.7%. In 2015 the projected population is 48,366,270. The
crude birth rate is 41.6 per 1,000 people, and life expectancy at birth is 63 years for women
and 60 years for men. Less than one third (29%) of the population resides in urban areas,
whereas the majority (71%) of the population are rural dwellers. (Tanzania Bureau of
Statistics, 2013)

10
The country‘s Gross Domestic Product (GDP) was USD $695 per capita in 2013 (World Bank,
2014). The Tanzanian economy is dependent on the labour intensive sectors of agriculture,
industry, mining and construction.

3.1.2 Health Statistics and Trends

Table 1 Health Indicators in Tanzania Mainland

Description Figure Sources

Total Population: 47.8 million (mainland) NBS 2015 projection
Under 15 years old 44.2% (mainland) NBS 2015 projection
15-64 years old 52.2% (mainland) NBS Census 2012
65 years& above 3.9% (mainland) NBS Census 2012
Women of reproductive age (15-49) 24.3% (mainland) NBS 2015 projection
Annual Population Growth rate 2.7% NBS Census 2012
Life expectancy at birth (years) 61 (63 F, 60 M) NBS Census 2012
Total Fertility Rate (TFR) 5.2 NBS Census 2012
Under 5 Mortality Rate /1,000 live births 81 TDHS 2010
Infant Mortality Rate / 1,000 live births 45 NBS Census 2012
Neonatal Mortality/1,000 live births 26 TDHS 2010
Maternal Mortality Ratio/per 100,000 live birth 432 NBS Census 2012
Births in health facilities 77% HMIS 2014
Skilled Birth Attendance 69% HMIS 2014
Leading Cause Admission/Death in Hospitals Malaria SPD 2013
Prevalence of Malaria Parasitemia (6-59 9.2% (MRDT), THMIS 2012
months) 4.1% (micro)
HIV Prevalence, 15-49 years 5.3% (6.2% F, 3.9% M) THMIS 2012
ART Coverage persons with advanced HIV 67% AHSPPR HMIS 2013
Hospital admission per 100 persons per year 2.4 HMIS 2014
OPD visits for new cases per person per year 0.64 HMIS 2014

The trends in Child Mortality and Infant Mortality are downwards; and Tanzania is expected
to meet the targets of the MDGs in 2015. The trends in neonatal mortality and maternal
mortality are also downwards, but less, and not meeting MDG targets. According to the
HSSP III MTR analytic report, the skilled births attendance rate is slowly increasing (around
62% in 2012). Figures on antenatal care are hardly improving and ANC 4 th visit even reduced
to 39% in 2012. These figures missed the target from HSSP III. Family planning figures are
low (Contraceptive Prevalence Rate 27.4%), while the total fertility rate is very slowly
reducing, also below target.

Figures on child vaccinations are very high with coverage of measles vaccination over 95%,
as well as for (DPT) Penta vaccination. The rate of underweight children under five is
reducing, but stunting remains high (42% TDHS) and off-target.

Malaria is the leading cause of morbidity, although slowly reducing in children under-5 years
old (33% of all registered diseases in 2012). Malaria meanwhile is the leading cause of death
of hospital admitted patients (around 30%). Prevention is improving: nearly 75% of
vulnerable groups slept under a bed net in 2012. The second largest cluster of diseases
consists of upper respiratory tract infections and pneumonia, followed by diarrhoeal
diseases and skin diseases.

Although the 2012 Tanzania HIV and Malaria Indicator survey (THMIS) depicted a decline in
HIV prevalence from the previous THMIS 2008, from 5.7% to 5.3%, the difference was not

11
statistically significant. The overall prevalence of HIV has not diminished, although the
numbers of patients treated continues to rise. By the end of December 2014, Tanzania had
1,411,829 of its population living with HIV, of whom 28% are children under 14, and 11.2%
of whom are young people aged 15-24. There are nearly 80,000 new HIV infections occurring
annually. Adult non-communicable diseases are slowly increasing, to nearly 10% of all
diagnoses in 2012. Life style related diseases like diabetes type 2 and cardio-vascular
diseases are increasing.

Overall the health status of the population is improving, with differences between urban and
rural areas, whereby some regions show an unfavourable epidemiological profile. There are
also differences between socio-economic strata with on average a poorer health status
among deprived groups (HSSP III MTR-Analytic Review 2013).

3.1.3 Health and Social Welfare Service Structure

Primary health care services constitute the basis of the pyramidal structure of health care
services (figure 4). Community-based health activities bring health promotion and
prevention to the families in villages and neighbourhoods, often along the lines of Disease
Control Programmes. Public and private providers are working in dispensaries and health
centres. Dispensaries provide preventive and curative outpatient services, while health
centres can also admit patients, and sometimes provide surgical services.

Council hospitals provide health care to referred patients and provide medical and basic
surgical services. Regional Referral Hospitals (RRH) function as referral hospitals to provide
specialist medical care. Zonal and National Hospitals offer advanced medical care and are
teaching hospitals for medical, paramedical and nursing training.

Pharmaceutical services are provided through public as well as Faith Based Organisations’
(FBO) health facilities, private pharmacies and Accredited Drug Dispensing Outlets (ADDOs).

Social services are provided by social welfare officers and social workers under the Councils
or by non-governmental organisations, supervised and coordinated by the Head of the Social
Welfare Department (SWD) of the Council.

Figure 4 The health care pyramid in Tanzania (public and private equivalent)

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Table 2 Current health service facilities (public and private)

Public Sector Facilities including FBO (2014) Number Total No. Of Beds
National general hospitals 1 1,362
National specialised hospitals 4 1,497
Regional referral hospitals (Gov) 15 3,449
Regional referral hospitals (FBO) 12 4,581
Zonal hospitals 5 2,327
Council hospital 63 7,267
Council designated hospital 37 6,742
Voluntary Agency hospital 103 5,595
Parastatal hospitals and health centres 29 1,214
Health centres 614 14,959
Dispensaries 5,819
Parastatal dispensaries 168
Specialised clinics 12
Total 6,882 48,993

Private Sector Facilities (2014)

Private hospitals 39 1,187
Private health centres 78 800
Dispensaries 1,123
Private clinics 40
Private dental clinics 26
Private eye clinics 5
Maternity homes 22
Total 1,333 1,987

Health Sector (Total) 8,215 50,862

Source: MOHSW, Department of Curative Services, HMIS report 2013/14, CSSC 2015

3.1.4 Management of Health and Social Welfare Services

Tanzania has decentralised most Government functions through Decentralisation by

Devolution (D-by-D). The PMO-RALG is responsible for the management and administration
of public services at Regional and Council level. At the local level the LGAs are responsible
for planning, delivering and overseeing public services, for example health services, social
welfare services, primary and secondary education, agriculture extension and livestock,
water supply, and local road maintenance. LGAs and facilities owned by LGAs have
responsibilities in social accountability and in establishing partnerships with communities,
NGOs and private providers in health and social welfare. They are the main interface
between citizens and Government in day-to-day life.

The Council Health Management Teams (CHMTs) manage health care and social welfare
services at the Council level. Council health services consist of Primary Referral Hospitals and
Primary Health Care Facilities (health centres and dispensaries). The LGAs employ personnel
working in Council health services. All CHMTs produce an annual Comprehensive Council
Health Plan (CCHP), which shows the activities and budgets for the services. There are still
many activities off-plan and off-budget, initiated through NGOs or Disease Control
Programmes (HSSP III-MTR 2013).

13
Health Facility Governing Committees (HFGCs) and Council Health Services Boards (CHSBs)
are bodies with community representatives that ideally contribute to management of the
health institutions, but which are sometimes dysfunctional (HSSP III-MTR 2013).

The Regional Health Management Teams (RHMTs) work under the Regional Administration
under PMO-RALG. They have as role to oversee the work of the Regional Referral Hospitals
and the CHMTs. RHMTs provide technical and administrative support to those entities.

The Department of Health (DOH) in PMO-RALG oversees the Council and Regional health
services administratively. PMO-RALG supervises planning, reporting and financial
accounting. It follows local government procedures, which have their own management
systems, for example software of EpiCor and PlanRep.

The MOHSW has the overall responsibility over the health and social welfare services and
defines priorities for services in the health and social welfare sector, e.g. the National
Essential Health Care Interventions Package – Tanzania (NEHCIP-Tz) (See Section 5.3). The
MOHSW provides technical guidance to organisations involved in service delivery and
defines, controls and promotes maintenance of quality standards and sets the policy for
social welfare, see Figure 5 below. The MOHSW mobilises resources and has the lead in
policy and international relations in the area of health and social welfare. The MOHSW
delegates some stewardship functions to PMO-RALG and other statutory health agencies,
e.g., Medical Stores Department, Tanzania Food and Drug Authority, etc.

Figure 5 Relations between levels of management in health and social services

MOHSW PMO-RALG
DOH

RAS
RHMT

Technical
Administrative

LGA
CHMT

The Ministry of Finance (MOF) manages the overall revenue, expenditure, and financing of
the Government of the United Republic of Tanzania and provides the Government with
advice on the broad financial affairs of Tanzania in support of the Government's economic
and social objectives. Its duties include preparing the Central Government budget and
determining expenditure allocations to different Government institutions. The Ministry has

14
an important say over the health and social welfare sector budget and also over income
generating activities (e.g., insurance schemes).

The President's Office, Public Service Management (PO-PSM) assists in matters of human
resources management pertaining to Public Service across the entire government system.
This includes responsibilities for personnel policies, administration and coordination of
training and recruitment. This office plays a crucial role in human resources for health in the
country.

3.2 Service Delivery of the Health and Social Welfare Sector

3.2.1 Services in Community and Health Institutions

Communities
There are a broad range of community-based programmes for disease prevention and
control, e.g., in malaria (bed nets and spraying), HIV/AIDS, TB, sanitation, hygiene, and
community based rehabilitation. However, relatively few communities are reached with a
comprehensive set of interventions. Activities mainly depend on local programmes and
funding, often by NGOs. Preventive chemotherapy against Neglected Tropical Diseases
reaches a geographical coverage of above 60% countrywide.

Health institutions
Over the period 2009 to 2014, the Government has expanded the number of health
institutions with around 500 mainly primary health care facilities and has increased the
number of health workers deployed. In 2013, sixty six thousand (66,000) health workers
were employed, out of the 149,000 required. Per capita utilisation of outpatient health
services did not increase significantly during the HSSP III period and was around 0.7 per
capita in 2013. This is attributed to low quality of care and limited access to medicines and
products. The Regional Referral Hospitals are still facing shortages of specialists and are
struggling with quality issues. Some are failing to cope with the demands for services, due to
shortages of personnel, supplies and equipment, and limited revenues.

Services, such as Integrated Management of Childhood Illnesses (IMCI), malaria,

tuberculosis, HIV prevention and control, Sexually Transmitted Infections (STIs),
Reproductive Maternal Newborn, Child and Adolescent Health (RMNCAH) and Prevention of
Mother to Child Transmission (PMTCT), are increasingly delivered in an integrated way at the
primary health care level (“one-stop-shop”), while the utilisation of these services is
improving. Services for Non-Communicable Diseases are still not yet provided according to
the needs of the population, based on epidemiological estimates.

The MOHSW has developed the Tanzania Quality Improvement Framework (TQIF) and a
Quality Improvement Strategic Plan (2013-2018), with guidelines, tools and training for
improvement of the quality of service delivery. The Quality Improvement (QI) programme is
still expanding.

The country has developed a good system for addressing health emergencies; however,
implementation is often constrained by lack of human and financial resources.

15
3.2.2 Disease Control Programmes

The trend analysis of the progress for the HSSP III indicators showed Tanzania would achieve
most of targets in the strategic plan in disease control and child health. The targets set in the
HIV/AIDS strategic plan for the period 2009–2013 are likely to be achieved, particularly for
those in the areas of utilisation of HIV/AIDS care and treatment services. Activities are noted
for increasing safe blood supply, safety of injections, access to voluntary medical male
circumcision etc. However, marginalised groups, like people who inject drugs, sex workers,
men who have sex with men and people living with disabilities or mentally handicapped, get
insufficient attention. HIV prevalence is decreasing only slowly, while women remain more
at risk than men. Challenges include the large gap between adult and paediatric anti-
retroviral treatment coverage, weak integration of HIV within RMNCAH services, and lack of
age-disaggregated data to understand the situation regarding coverage of HIV and Sexual
and Reproductive Health services among adolescents.

The malaria strategies for the period 2009–2013 are successful, particularly for malaria
diagnosis and treatment and the distribution of insecticide-treated nets (ITNs). Three-
quarters of the population, in all wealth quintiles, now use ITNs.

TB and leprosy strategies for the period 2009–2013 have generally been implemented
according to plan. However, new estimates following the first TB prevalence survey in
Tanzania indicated much lower case detection rates and less TB-HIV co-infection than
previously estimated. Most of the progress of the TB programme can be attributed to the
home-based Directly Observed Therapy, Short course (DOTS) strategy. An area with limited
progress is leprosy elimination and prevention of disabilities.

Most HSSP III strategies for Neglected Tropical Diseases (NTDs) for the period 2009–2014
were being implemented on an expanded scale, in particular surveillance, diagnosis and
treatment. Around 64% (101 out of 160) of the Councils where NTDs are endemic are
implementing Integrated NTD control activities. Good progress has been made in
Onchocerciasis control, interrupting transmission of Lymphatic Filariasis and Trachoma.

Recent surveys have provided much more insight into the upcoming epidemic of non-
communicable diseases (NCDs). Urbanisation and social change are increasingly leading to
unhealthy lifestyles (e.g., poor diet, excessive salt intake, limited physical activity). The
planned NCD strategies for the period 2009–2013 have not been implemented as planned.
Tackling the relevant risk factors for NCDs has yet to start.

3.2.3 Reproductive, Maternal, Newborn, Child & Adolescent Health and Nutrition

Reproductive Health Services (RHS) are not performing as hoped in Tanzania, despite
investments in this area. Most of the targets of HSSP III in this area are not being achieved.
The number of facilities that offer RHS is increasing; however, the facilities face shortages of
skilled staff and in supplies. There was a slight increase in skilled birth attendance and in
post-natal care during the HSSP III period, as well as in utilisation of Family Planning (FP)
services. (See statistics under 3.1.2.) In many rural areas, the pace of quality improvement
and availability of health services lags behind that of urban areas. In the BRN planning
process, under-performing regions with significant numbers of rural populations have been
identified for priority action. Expansion of service delivery has not been moving in tandem
with improved quality of services delivered, and especially referral of complicated maternal
cases in rural areas is still insufficient.

16
Most child health programmes are performing well, with the exception of newborn care
(related to poor quality of maternal health care around birth), which is a serious concern,
given the high neonatal mortality in the country. Vaccination services are well on track and
nearly all children are vaccinated; at the national level, the coverage of all antigens has been
maintained above 90% for three consecutive years. Four new and under used vaccines
Rotavirus vaccine, Pneumococcal vaccines, Combined Measles Rubella vaccine and 2 nd dose
of Measles Rubella have been introduced in the routine immunisation schedule. Coverage of
the newly introduced vaccines has not yet reached 90%. Despite high coverage of
vaccinations, there are districts with few geographic or wealth-related inequalities. These
districts have a high number of children who are not vaccinated or under-vaccinated.

There has been a gradual improvement in the nutritional status of children in Tanzania, but
stunting remains a problem because of repeated episodes of ill health of children and
inadequate infant and young child feeding practices. Stunting remains a problem with
prevalence of 42% among under-five children (DHS 2010). Exclusive breastfeeding is not yet
a common practice in the country, especially in rural areas. There has been no improvement
on prevalence of micronutrient deficiencies among children and women of reproductive age.
Coverage of Vitamin A Supplementation (VAS) has increased significantly.

3.2.4 Social Welfare

The Department of Social Welfare (DSW) is responsible for services to vulnerable

populations in communities or in institutions. Social Welfare Officers in Councils are
responsible for the provision of child protection services and supervision of other welfare
services. Integration of Social Welfare Services in LGAs is still challenged by inadequate
capacities to handle complexity and emerging social welfare problems and by financial
constraints.

In addition to social protection services, social welfare officers have a legal responsibility
under the Law of the Child Act for the delivery of child protection services for local
government authorities. The Violence against Children Report published in 2011 noted the
high levels of physical and sexual violence and the physical and mental health consequences
of suffering such abuse, as well as the social and cultural legitimacy of violence. The Second
National Costed Plan of Action (2013-2017) and the Multi-sector Task Force on Violence
against Children, Implementation, Monitoring and Evaluation Results Framework Plan all
give prominent attention to the need of developing services to protect children from all
forms of violence. An initial pilot project in eight Councils has now been extended to 15
Councils.

The Government is only in the early stages of developing services for children who are
without parental or family care, and have yet to develop fully the fostering, fit persons,
adoption and residential services necessary to meet need. At present, social welfare services
for children are assisted by the Most Vulnerable Children Committees, which have been
established in virtually all Councils. NGOs provide most of the residential care, but a rigorous
monitoring and inspection framework has yet to be developed.

In addition to child protection services, the Government provides social protection services
through other ministries and through the Tanzanian Social Action Fund (TASAF). External
agencies (multi-laterals, bi-laterals, non-governmental and faith-based organisations, etc.)
are important partners in local service provision, but are unable to reach the whole country,
leading to inequities in access to services. External agencies may also apply their own criteria
for access to services.

17
Special programmes for disabled people are in place in some regions in the country. There
are community based rehabilitation services (mostly run by NGOs), and some institutions
provide care and rehabilitation. There are four centres for surgical care for disabled people.

Social Welfare policy issues include financing access to essential education and health care
services among the vulnerable population groups, which needs to be anchored within a
comprehensive Social Welfare Policy and supported with social welfare legislative
provisions. Access for the poor to health insurance schemes is an upcoming issue for Social
Welfare Officers in the country.

In 2014, an Inter-Ministerial Memorandum of Understanding was signed for the

Implementation of the National Under-Five Birth Registration Strategy between Ministry of
Constitutional and Legal Affairs, PMO-RALG, and MOHSW. Health facilities increasingly play
a role in the system of Birth Registration because the majority of children are born in health
facilities and nearly all children are vaccinated. Tanzania follows the internationally agreed
“Reaching Every Child” (REC) approach.

3.3 Health Care Support Systems

3.3.1 Human Resources for Health

Human Resources for Health (HRH) planning is improving at the Council level, strengthened
by a functional Human Resources Information System (HRIS). Bottlenecks in HRH
management are still prevalent, leading to limited absorptive capacity in the system (as
thoroughly analysed in the BRN planning process). As a result, newly trained staff have
problems finding quickly employment, while vacancies exist.

The number of health workers, especially clinical personnel, is increasing. However, remote
and rural areas still face major shortages and many primary health facilities do not have
enough qualified staff, resulting in an inefficient use of resources. This has been identified as
one of the key constraints in the NKRA formulation. Population ratios for laboratory and
pharmaceutical personnel remain well below expectation. Critical under-financing and
limitations enforcing the Public Service Pay and Incentive Policy (2010) intensify the
misdistribution or shortage of health workers.

The system of performance management not fully operational; the Open Performance
Review and Appraisal System (OPRAS) is only partially implemented and actually unpopular
among the administrators who are supposed to put it to use.

The output of training institutions has increased considerably over the last several years, but
the quality of training is not yet consistent. Continuing Professional Development (CPD) has
limited continuity; the impact on the health system as a whole is insufficient, as the
approach is fragmented and ad-hoc. There is no system of accreditation and re-registration
of professionals based on attending CPD. There is no system of quality assurance of
competencies of health professionals.

18
Table 3 Health workforce supply in the base year 2014

Occupation Supply % of the % FTE in FTEs by sector Density of

in 2014 total public health
work- sector worker per
force 10,000
population
Public Private
1.Medical Specialists 929 1.4 70.0 650 279 0.20
2.Medical Doctors 1,157 1.7 80.0 926 231 0.25
3.Dental Specialists + Dental Officers 104 0.2 95.0 99 5 0.02
4.Assistant Dental Officers + Dental 933 1.4 87.7 818 115 0.20
Therapists
5.Assistant Medical Officers 1,710 2.6 90.0 1,539 171 0.37
6.Clinical Officers + Clinical Assistants 6,496 9.8 70.0 4,547 1,949 1.42
7.Pharmasists 707 1.1 96.5 682 25 0.15
8.Pharmact Technologists + Assistant 1,132 1.7 95.4 1,080 52 0.25
Pharmacy Technologists
9.Nursing Officers 2,843 4.3 97.7 2,777 66 0.62
10.Assistant Nursing Officers 4,861 7.3 90.0 4,375 486 1.06
11.Enrolled Nurses +NMs 13,848 20.9 80.0 11,078 2,770 3.03
12.Health Laboratory Scientists 93 0.1 89.2 83 10 0.02
13.Health Laboratory Technologists + 2,508 3.8 92.1 2,310 198 0.55
Assistant Health Lab. Technologists
14.Environmental Health Officers 1,205 1.8 99.8 1,202 3 0.26
15. Assistant Environmental Health 1,119 1.7 100.0 1,119 0 0.24
Officers+ Environmental H. Assistants
16.Allied Health Professionals 1,245 1.9 97.5 1,214 31 0.27
17.Managers 384 0.6 98.4 378 6 0.08
18.Allied non-Health Professionals 2,235 3.4 91.5 2,046 189 0.49
19.Support Staff 3,460 5.2 95.6 3,309 151 0.76
20.Medical Attendants 19,379 29.2 96.1 18,632 747 4.24
TOTAL 66,348 100.0 88.7 58,864 7,484 14.50
Source: MOHSW, Human Resources Planning Division, Human Resources for Health Information Systems (HRHIS)
and Training Institutions Information System (TIIS) (2014)

Social work is a relatively new profession in Tanzania. At present there are an inadequate
number of trained social workers to meet the needs of all LGAs (four social welfare officers
in each Council and a social assistant at each ward). The Department of Social Welfare is
enhancing the professionalism of social workers through both formal training and short
courses. A common core of training materials has been developed and common modules
will be made available for all training institutes and organisations during the period of HSSP
IV. The MOHSW is planning to implement a Social Welfare Workforce Production Plan, which
ensures that the increased workforce is capable of managing emerging and complex social
problems. The Social Work Council and the Association will be facilitated to undertake their
duties to enhance professional conduct in social welfare functions.

3.3.2 Essential Medicines and Health Products

The availability of key medicines in health facilities remains low, with no clear trend of
improvement during HSSP III. A number of factors (internal and external) affect overall
management of commodities in the sector. According to the BRN analysis, internal factors
include inadequate funding, poor planning and coordination, inadequate tracking
mechanisms and tools, as well as inadequate pharmaceutical human resources at the facility

19
level resulting in poor inventory management. External factors include a lack of coordination
of externally funded vertical programmes’ medicines and health products and donated
supplies, and pilferage. This negatively affects the quality of care and performance of service
provision in general.

The number of Accredited Drug Dispensing Outlets (ADDOs) has increased from 2,215 in
2010 to 3,591 in 2013, leading to better availability of some medicines and health products
in rural areas. However there are still some challenges with sustaining quality of services and
products within ADDOs. Ensuring the rational use of medicines is still a major challenge in
spite of some positive developments that include the development of Medicines and
Therapeutics Committee (MTC) guidelines, training on MTCs at public sector hospitals and
the update and wider distribution of Standard Treatment Guidelines and National Essential
Medicines List.

Funding of medical supplies is not improving in real per capita terms and disbursement
issues continue to affect the efficient use of limited funds. Budgetary shortfalls are
exacerbated by disbursement practices (e.g., less than approved budget is disbursed by
Treasury to the MOHSW; irregular disbursements, late in the financial year; long lead times
for disbursed funds to be credited to health facility accounts at MSD). In addition, failure to
budget for distribution costs for externally financed products has eroded MSD working
capital. MSD's limited cash flow negatively affects the stock levels and order fulfilment rate
for medicines and other products. Local manufacturing to increase availability of medicines
in the country is still low at about 30% of the requirements.

On the positive side, better procurement and information management procedures are
under development (e-LMIS), with the potential to increase efficiency, reduce waste and
improve availability of medicines to the population. Similarly the regulatory framework
through the Tanzania Food and Drug Authority (TFDA) has improved over the years. TFDA
was able to increase the annual number of medicine samples to be tested (from 340 to 675
between 2010 and 2012), as well as the number of samples actually processed (from 52% to
96% between 2010 and 2012) in its WHO pre-qualified quality control laboratory. However,
there are still medicines and health products of questionable quality and some are not
registered circulating in the market.

3.3.3 Capital Investment

The health sector infrastructure in Tanzania is expanding, especially the number of

dispensaries (around 500 in the past five years). In some regions in the country the number
of facilities is still inadequate. The number of staff houses is insufficient, and most of the
health facilities in remote areas lack electricity and reliable water supply. Construction
activities over the last years have exceeded the deployment of staff, leading to
underutilisation of the infrastructure and thus efficiency losses. The MOHSW does not have
a meaningful role in quality control of infrastructure and does not have a good overview of
available health institutions in the country, especially not the private facilities.

Infrastructure maintenance is a major challenge, affecting the majority of institutions.

Maintenance of equipment is not yet a priority for health facilities, and this has a negative
impact on the effectiveness and quality of service delivery. Equally, acquiring and
maintaining means of transport is a challenge for most institutions.

20
3.3.4 Monitoring and Evaluation

A comprehensive Monitoring and Evaluation Strengthening Initiative (MESI) has been

developed and implemented since 2009. The customised DHIS-2 software was disseminated
and health workers were trained. Indicators across the HMIS tools were harmonised and
data collection tools for Disease Control Programmes were realised, allowing for integration
of systems. Developments in information and communication technologies are paving the
way for establishing the clearing house and have a potential to change the face of health
service delivery.

The reporting systems of the PMO-RALG and MOHSW are still in the process of integration.
The quality of analysis of available information requires further coordination and capacity
development for this to be institutionalised: the data-for-decision making approach is not
yet commonplace in most CHMTs and RHMTs. More sex- and age disaggregation of many
health service indicators are also needed in order to understand gaps in coverage.

The country has a well-established system of sentinel surveillance to assess performance

and regular surveys to get information on trends in development, demography, poverty,
health and social wellbeing. Research is increasing and national reports are more available;
the research outputs are not yet incorporated in the health information-clearing house.

3.3.5 Health Financing

Countrywide measures for removing financial barriers for the population are slowly taking
off. The Community Health Fund (CHF) and TIKA (a scheme for urban, peri-urban areas) aim
at reduction of health care costs in primary care. The highly needed Health Financing
Strategy (HFS) under development aims at providing universal and equitable access to
essential health services, while improving sustainability of the health sector.

There has been progress under HSSP III in improving financial management as an avenue
toward greater efficiency and effectiveness, but aligning various types of resource
management from non-basket partners is still a challenge.

Through a participatory process led by the MOHSW, a new HFS has been developed, which
will align with the HSSP IV and continue thereafter as the country aims to achieve universal
health coverage. The HFS shares the vision of HSSP IV in improving the quality of health
services and increasing equitable access. One of the key barriers to improvement in quality
and access is the lack of effectiveness and efficiency in health financing. It is recognised that
the health financing architecture is fragmented, which means that individual health
insurance schemes are covering different population segments, rather than combining them.
They do not yet achieve efficiencies in scale and cross-subsidisation (by creating one joint
risk and financial pool). Furthermore the large number of different funding streams, health-
purchasing agencies (e.g. health insurances) and different regulatory institutions are also
making financial stewardship of the health sector challenging. The HFS aims to solve these
problems by moving towards a more sustainable and efficient architecture for raising
(particularly domestic financing), combining, and deploying overall funding for health, with
defined roles for certain critical institutions.

21
Figure 6 Percentage of GOT budget 2006/07 - 2014/15

Source: PER presentation to JAHSR 2014

There is growth in the total health expenditure in Tanzania, but the per capita expenditure
corrected for inflation remained flat in the HSSP III period. Tanzania spends between 9% and
10% of its budget on health. See figure 6 above. The public health budget has become
increasingly reliant on foreign funds.

Figure 7 Total Health Expenditure by Financing Source and Financing Agent

Source: National Health Accounts 2011/12

The Health Basket Fund plays a crucial role in health care financing, although in recent years
contributions are dwindling. The funds offer the LGAs assured opportunities for
implementing service delivery. The demands and capacities in LGAs for timely accounting
and reporting do not always match the requirements. However financial decentralisation is
aimed at conferring autonomy to health facilities on financial management.

22
3.3.6 Leadership and Governance

In recent years, new health and social welfare legislation has been enacted. However, there
is still limited understanding of the holistic nature of health and social welfare legislation.
Similarly, laws are not self-executing instruments; additional support is needed to empower
all those who are statutorily mandated to oversee their implementation. This lack of
understanding has affected the implementation by relevant stakeholders. Furthermore,
there is a number of health and social welfare related international conventions or
agreements initiated by other sectors and partners, which need to be adopted and
implemented. Based on this, specific implementation support is needed in order to ensure
enforcement and compliance of relevant legislation.

There is viable operational planning at all levels of the health sector. Decentralisation by
Devolution is progressing, but requires further harmonisation of systems by the MOHSW,
PMO-RALG, PO-PSM and MOF as well as reaching the communities and households in a
coordinated coherent manner.

A key strategy for the strengthening of public governance in Tanzania is through the concept
of public-private partnerships (PPPs). PPP has been properly developed, with strategies,
tools and instruments for operationalisation, as well as advocacy and training at national,
regional and council levels. Service Agreements (SAs) are in place between LGAs and faith-
based health service providers. Some Councils face constraints in meeting the financial
obligations of those agreements. The potential for expansion is not yet fully utilised to make
a significant impact on the sector. The private-for-profit sector is not yet fully organised and
has not yet managed to enter into Service Agreements.

With regard to the Sector Wide Approach (SWAp), the arrangements laid down in the Code
of Conduct and Basket Funding Agreements provide a model for the sub-Saharan region. The
Technical Committee-SWAp and Joint Annual Health Sector Review (JAHSR) are outstanding
instruments for collaboration between stakeholders, with open and transparent discussions.
However, efficiency of procedures has to increase, and harmonisation between monitoring
of HSSP IV and SWAp is required.

Recent reviews and studies (MTR HSSP III) have endorsed the principles and operation of the
SWAp but have also highlighted some weaknesses in its operations. The participation of civil
society is still limited and other Ministries, Departments, Agencies (MDAs), especially PMO-
RALG, face constraints in attending meetings.

The Technical Working Groups (TWGs) are an asset for joint planning and implementation
but are not always functioning as desired. Attendance varies and there is overlap with each
other and with other committees or task groups. The coordination or exchange of
information across TWGs is not optimal and weak linkages are maintained with the
management structure of the MOHSW.

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4 Strategic Framework for the Health Sector
4.1 Introduction

Strategic Direction: As Tanzania is heading towards middle-income country status, its

performance in health care and social welfare services will head towards that of other
middle-income countries (both in coverage and quality). Better health will contribute to
increasing productivity and growth as well as rising GDP.

The health and social welfare sector follows the overall Tanzania Development Vision 2025:
achieving a higher quality of life for the people of Tanzania at the status of a middle-income
country and a health care and social welfare system at this level of development. The
Tanzania Health Policy defines the Vision 2025 Goals for the health sector. The Big Results
Now (BRN) Programme accelerates developments toward Vision 2025 and has formulated a
set of tangible objectives and targets for the health sector (see Section 2.)

Sustainable Development Goals (SDGs)

The SDGs provide the strategic context for international development, and more specifically
Universal Coverage of health and social welfare services. The SDGs compel this HSSP to take
forward the unfinished agenda from the MDGs with more attention paid to maternal health
(MDG5). Also, sustaining gains made in child health indicators (MDG4) and primary and
secondary prevention gains in the high burden communicable diseases (malaria, TB, HIV)
receive attention along with addressing conditions resulting from epidemiological transition
in terms of prevention and management of NCDs. The challenge posed by NCDs presents a
sufficient justification for addressing social determinants of health in education,
environment, economic, cultural and other sectors: to this end, sustainable measures for
poverty eradication, environmental protection and preservation, household food security,
quality basic education for all and healthy lifestyles shall be promoted in the context of
health in all policies.

Figure 8 Strategic Framework for HSSP IV

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4.2 Mission and Vision of HSSP IV

The Mission, Vision and Core Values are crosscutting for all activities in the sector,
integrated in all work plans of all stakeholders in the sector.

The mission of the health and social welfare sector is derived from the Vision 2025 and is
“the provision of basic health and social welfare services that are of good quality, equitable,
accessible, affordable, sustainable and gender sensitive”.

The vision of the health and social welfare sector is “to have a healthy society with improved
social wellbeing that will contribute effectively to individual and national development.”

4.3 Overall and Specific Objectives of HSSP IV

The mission and vision of the health and social welfare sector inspire the Overall and Specific
Objectives, which elaborated in this strategic plan.

The overall objective of HSSP IV is to reach all households with essential health and social
welfare services, meeting as much as possible expectations of the population and objective
quality standards, applying evidence-based, efficient channels of service delivery.

The specific objectives are:

1. The health and social services sector will achieve objectively measurable quality
improvement of primary health care services, delivering a package of essential services in
communities and health facilities

Quality Improvement of primary health care and social welfare services in communities,
households and primary health care facilities will be the major focus of HSSP IV, enhanced by
the BRN activities under four Key Result Areas. The health sector will take the BRN approach
further, to all regions in the country and beyond 2018 (when phase one of the BRN
programme ends). Targets for quality improvement (to be achieved by 2018) are:

 20% reduction in maternal mortality ratio and neonatal mortality rate in 5 poorly
performing regions: Maternal and newborn services shall reach under-served areas and
meet the quality standards for primary and referral care (see Section 5.4.)

 100% balanced distribution of skilled health workers at primary level in targeted

underserved regions: Recruitment, retention and (re)distribution of Human Resources
for Health (HRH) will ensure adequate staffing of all primary health care facilities.

 80% of primary health facilities to be rated 3 Stars and above by 2018: The process is
guided by the Star Rating system for primary level health facilities, which sets objective
criteria for minimum standards to be achieved. The further development of a stepwise
certification and accreditation system and linkage of quality to insurance payments will
stimulate the health facilities to go beyond 3 stars as further development from the BRN
priming (see Section 5.1). Performance management systems and involvement of health
facility teams in self-assessments will stimulate health staff and social welfare workers
to provide quality services (see Section 6.1). There will be measures to enforce
accountability and deter pilferage and corruption. Cases of corruption will be dealt with
immediately through the legal framework of the government of Tanzania.

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 100% stock availability of essential medicines: Quality will also improve through
adequate supply of medicines and health products (see Section 6.2) and through
refurbishment and equipping of health facilities (see Section 6.4).

For social welfare, quality will be maintained through the creation of an inspectorate and
development of a monitoring framework. The health and social welfare sector will ensure
that essential services are provided. It will further refine the National Essential Health Care
Intervention Package (NEHCIP) as well as a Minimum Benefit Package for the Single National
Health Insurance (see Section 5.3). Promotion of healthy living and an environment
conducive for healthy households and workplaces will help to achieve a quality living
standard in health and social welfare among communities. Prevention of communicable and
non-communicable diseases will receive high priority (see Section 5.3). The country will
address nutrition issues, especially stunting of under-5 year old children (see Section 5.4).
Improved quality will generate trust in the national health and social welfare services and
will stimulate people to join the Single National Health Insurance. It will stimulate people to
take greater ownership of the health services in their communities.

There will be emphasis on applying human rights based approach in health programmes and
clients’ rights by revitalising the Client’s Charter (see Section 7.3). In social welfare the rights
of vulnerable groups (persons with disabilities, orphans, elderly, female headed households,
persons with chronic diseases, homeless, etc.) will be protected. MOHSW and partners will
engage in a public awareness campaign to sensitise the population about their rights and
responsibilities and will reach all households (see Sections 5.2. and 7.3).

2. The health and social welfare sector will improve equitable access to services in the
country by focusing on geographic areas with higher disease burdens and by focusing
on vulnerable groups in the population with higher risks.

Under HSSP IV, significant steps will be made to increase equitable access by improving the
geographical spread of health services, as well as individual and social protection through
the Single National Health Insurance (SNHI).

 The BRN focus on most underserved Regions and Councils, where health outcomes are
below average, will enhance equity of access for rural populations. Under this strategic
period, (re)distribution of qualified staff over the country will receive attention in order
to improve accessibility of services (see Section 6.1).

 Improving community health services by professional Community Health Workers in

integrated health programmes will include a Social Welfare Attendant that will attend to
social welfare issues at grassroots, also in areas where distances to health facilities are
bigger (see Section 5.3).

 Further integration of social welfare and health services and closer collaboration with
other ministries, agencies and non-governmental organisations will make social welfare
services more accessible to people in need of assistance (see Section 5.7).

 Reproductive health will be a major priority for the health sector, with special attention
for access to care by vulnerable groups (see Section 5.4). Adolescent girls and young
women are at a higher risk of HIV infection and will receive adequate care (see Section
5.4).

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 Gender equity will receive increased attention in concrete measures, e.g. focus on
prevention of HIV amongst adolescent girls, addressing violence against women. Also in
committees and boards equal representation of women will be prioritised (see Section
7.3).

The health sector will continue the BRN approach during the whole HSSP IV period, which
includes priority setting based on epidemiological analysis, targeting under-served
populations and vulnerable groups, and responding to high priority health needs.

3. The health and social welfare sector will achieve active community partnership through
intensified interactions with the population for improvement of health and social
wellbeing.

Acceptability of the services will also improve by increased community health care guided
by:

 A newly articulated Community Based Health Programme, in partnership with

organisations in society, by revitalising primary health care and community based social
welfare services (see Section 5.3).

 More community participation in management of the health facilities will contribute to

regaining trust in the health care system and increased acceptability (see Section 7.2).

 The health and social welfare sector will engage with the population in modern
interactive communication via e-health to establish partnerships (see Section 6.5).

To ensure that interventions formulated in this strategic plan are measured and assessed
with beneficiary interests a system of social accountability will be put in place to strengthen
bottom-up planning, transparent reporting to Boards and Committees, by:

 Optimising mechanisms that provide room for community voice to be heard in health
care management (see Section 7.2).

 Promoting innovations such as user rating, customer satisfaction surveys, and a

community scorecard (see Section 7.2).

 Using information and communication technology to promote transparency, and

performance management (see Section 6.5).

 Strengthening monitoring and evaluation systems (see Section 6.4).

The new health care financing strategy, which promotes the development of a single
national health insurance with effective risk-pooling and social protection, will increase the
affordability of health care, also for the poorer citizens, and will enhance sustainable
development of the health care sector (see Section 6.6).

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4. The health and social welfare sector will achieve a higher rate of return on investment
by applying modern management methods and innovative partnerships.

Improvement of the health and social welfare services can be realised at a higher rate
through increased effectiveness and efficiency. Improving the technical competency of
health workers and their adherence to standards will increase overall effectiveness. Better
use of information systems will improve efficient communications and better inform
decision-making concerning the utilisation of scarce resources (see Section 6.4). In the
implementation of health sector interventions, partnerships across the health and social
welfare sector are crucial, at all levels. Public and private providers will work together in the
delivery of health services, with a view to give room for innovative approaches (e.g. new
contracting arrangements) in service delivery and for the promotion of private sector
engagement.

In health care financing, opportunities for public private partnership will be created which
allow the business community to enter into collaboration with public as well as private
partners in the health sector. Government will facilitate investments in the health sector
(see Section 6.6).

Recognising that the country is still largely relying on support from abroad for health and
social welfare services, the MOHSW will continue to uphold the Sector Wide Approach in the
health and social welfare sector, strengthening financing of one sector plan, country level
partnerships and international collaboration, while addressing donor dependency through
financial sustainability plans and exit strategies (see Section 7.4).

5. For improving the social determinants affecting health and welfare, the health and
social welfare sector will achieve close collaboration with other sectors, and advocate
for inclusion of health promoting and health protecting measures in other sectors’
policies and strategies. It will mobilise non-governmental and private partners to
promote health and wellbeing through their strategies.

The vision of the health sector is to have a healthy nation with improved social wellbeing
contributing to national development. Health is a valuable individual asset enabling people
to better contribute to social development. Improved health and social wellbeing of the
nation are essential towards realising the Nation’s Vision 2025. Investing in health is
therefore a necessity for the country to meet its development objectives.

The health and welfare sector alone cannot achieve the desired health and wellbeing for all
individuals. Social determinants of health and wellbeing, like nutrition, housing, safe water,
safe and hygienic environment, individual behaviours and security are crucial to realising
these goals. For addressing the social determinants of health, economic development,
housing, education, roads and communication are of great importance.

In order to achieve a healthier nation, health aspects must be part of policies in all sectors.
The MOHSW will be the advocate for policies protecting and advancing health and social
welfare, e.g., in reduction of point source environmental pollution, building resilient
interventions for the reduction of harmful effects of climate change, improve road safety,
protection from the double burden of Non-Communicable Diseases and Communicable
Diseases through promotion of healthier lifestyles, safety of consumer goods and food
products. The MOHSW will advocate for health impact assessments prior to major
developmental initiatives (see Section 5.5).

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Social welfare focuses on achieving acceptable standards of social wellbeing and protection
for vulnerable groups in society, and enables those groups to participate in society and
contribute to development of the country. Social welfare interacts with many other sectors,
like economic development, education, or food security. Like health, social welfare has to be
integrated in other sectors’ policies (see Section 5.7).

The private sector (companies, businesses, farms, etc.) plays a critical role in health and
social wellbeing of the population, not only by employing people, but also by producing
health products, or in some cases exposing people to health risks. Partnership with the
private sector is necessary in health promotion and health protection. Similarly, the non-
governmental sector contributes to service delivery, advocacy, awareness raising and
training, and is partner in both the health and social welfare sector. There is also a growing
awareness among private sector companies regarding their corporate social welfare sector
responsibility to their employees and to the communities where they operate. Currently,
corporate social responsibility is voluntary, but the private sector needs to be educated to its
benefits, both for individuals and for a company’s growth (see Section 7.2).

Advocating for informed health interventions in conjunction with all policies is not only a
responsibility for the MOHSW, but also for local and regional health and social welfare
organisations advising in decentralised government systems (see Section 7.2).

Annex 3, 4 and 5 shows relevant indicators for health sector performance, for BRN and for
HSSP IV implementation, with baseline and targets for the HSSP IV period.

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5 Service Delivery
5.1 Introduction

The Section on Service Delivery reflects strategic directions in services with an overarching
theme of quality assurance, which is presented first. Next, this Section presents the essential
health care intervention package per level of service delivery in the communities, primary
health care facilities, council and referral hospitals, and national hospitals. This Section
continues elaborating the types of services provided. Specific health services on promotion,
prevention and curative services for communicable and non-communicable diseases are
reflected in this Section. Finally, the social welfare services are presented.

Service delivery is the visible part of health care, the interface between the population and
the health sector. Health sector system building blocks that provide inputs for, and enable
service delivery are discussed in the next Section (see figure 1).

5.2 Quality Assurance

Strategic Direction: The primary focus will be on quality in order to improve outcomes of
health care and social welfare services and to enhance trust within the population and other
stakeholders in the quality of the sector’s services. A series of measures will make the quality
of health care visible, more acceptable to users, and safer for both clients and health
workers. Transparency in official processes and decision-making, as well as value, for money
will attract investments in the sector.

The health sector will introduce a step-wise improvement of quality of care as part of the
BRN approach and beyond. By 2020 over 80% of health facilities all over the country will
score good performance ratings in patient satisfaction surveys and 80% of the primary
health facilities will have a 3 Star Rating or higher.

Certification towards Accreditation

The ministry will introduce stepwise certification towards accreditation (SWCA) system
based on objective independent assessments of quality of service provision using an agreed
set of valid, quality of health care indicators. This will cover both service delivery topics and
support systems’ topics (see table 4 below). This will start with the introduction of a Star
Rating mechanism for all primary health care facilities under the BRN programme. The Star
Rating will provide a national overview of the status of these health facilities and guide
further priority setting for identifying bottlenecks for health facility quality improvements to
be addressed. Under-performing health facilities will get support from the Councils to bring
them up to the desired standard, e.g., refurbishment of infrastructure, recruitment of
additional staff, training, mentoring and supportive supervision. At facilities, there will be
improvements in the organisation of services, clinical care and support, emergency care and
in referral mechanisms.

The facilities attaining three stars and above will be enrolled in SWCA using Safe Care
international standards, to be adapted by the MOHSW. The phased introduction of the
SWCA system will roll out to incorporate hospitals. The health sector will establish an
independent body for accreditation of facilities.

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Table 4 Criteria for Star Rating of Primary Health Facilities

Assessment Area Characteristics of Facility at 5 Star level

Facility Management &  Strong governance structure with decentralisation of fiscal
Governance management
 Implements best practices for managing resources
 Appropriate skilled staffing complement as per staffing
establishment
 Excellent working conditions/environment for staff including
housing and appropriate incentives
Use of Facility Data  Accurate and comprehensive data
 Staff who can perform data analysis
 Staff who use data for service improvement
Staff Performance Assessment  Functioning performance system for staff
 Staff who have met over 80% of their performance targets
Organisation of Services  Well-organised setup for service delivery
 Well-organised and efficient process for maintaining and accessing
records
Emergency Care and Referral  Fully trained staff and a strong functioning system to triage, refer if
Mechanism needed
 Successfully handle emergency cases as per the norms for the
facility type
Client Focus and  Strong functioning HFGC/Council Health Service Board that is
Social Accountability responsive to the needs of the community
 Facilitates an inclusive planning process for HF plans and by fully
executing these plans
Health Infrastructure &  Consistently available power, running water, and functional
Infection Prevention Control equipment
 Infection prevention and control and waste management systems
that are implemented according to national guidelines
Clinical Services  RMNCAH, FP, outpatient and inpatient, and specialist services are
fully provided according to standard protocols
 Minimal patient waiting times
Clinical Support Services  Continuous availability of medicines that are appropriately stored
and rationally used
 Availability of quality diagnostic services according to the
standards of the facility type
 For HC and Hospitals, they must have fully functioning operating
theatre with measures in place to prevent sepsis

Clients’ Charter
Client and service provider rights and responsibilities are to be attained at optimal level with
maximum use of available resources. The health sector will review and adapt the Clients’
Charter that applies a human rights-based approach in health and social welfare. It will
introduce the Community Score Card (CSC) as a tool for social accountability. There will be
an automated system for receiving users’ ratings and complaints, being fed back to the
facilities. This will continuously assess customer satisfaction and guarantee fair client
complaints’ handling procedures and improve accountability to clients and communities.

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Quality Improvement
The safety and effectiveness of services, procedures and working environment will be
strengthened. The health sector will continue to standardise clinical management and use of
appropriate, safe and cost-effective medicines, and improve the availability of functional
medical equipment and high standards of diagnostic services. The health sector will
consolidate and sustain gains made under HSSP III in Infection Prevention and Control (IPC)
in Health Services Waste Management and in improving working environments.

The integrated Quality Improvement (QI) programme will implement a national QI toolkit
and monitoring system based on a commonly agreed set of QI indicators, capacity building
on QI that includes facility teams’ self-assessments as a key to the self-driven approach,
comprehensive supportive supervision, mentoring and coaching. There will be
harmonisation, coordination, integration and operationalisation of QI approaches among
disease control programmes and a mechanism for motivating quality improvement and
performance measurement and management at all levels. Quality will be mainstreamed by
incorporation into Comprehensive Council Health Plans (CCHPs) and a responsibility for
tracking and communicating quality matters to respective management and leadership shall
be formally assigned at all health facilities, CHMTs and RHMTs.

MOHSW will publish basic standards for health care provision from the community level to
the national level (Basic Standards for Heath Facilities, 2015). The MOHSW will ensure that
key information in the health and social welfare sector shall be translated, transcribed and
disseminated in a user-friendly format.

QI topics will be incorporated in all pre-service training programmes for health and social
welfare workers. The MOHSW will develop integrated training modules on QI assessments,
planning, implementation and evaluation for inclusion into health and social welfare training
curricula. In a move to widen quality thinking and practice, peer learning and exchange of
lessons and experiences from best practices shall be promoted at health care settings and
locally organised forums.

Pay for Performance

Linking payments by Health Insurance Funds, by companies or by Results Based Financing
(RBF) programmes to quality of services provided will enhance compliance with Standard
Operating Procedures (SOPs) and health care standards. Health facility management and
staff performance will be continually assessed and employees will be made accountable to
local governance structures.

Where necessary, more emphasis will be put on enforcement of laws and regulations, and
interventions from health professional councils, once standards have been developed and
disseminated and the involved persons have been trained.

5.3 Package of Intervention by Levels of Care

5.3.1 National Essential Health Care Intervention Package

The National Essential Health Care Interventions Package – Tanzania (NEHCIP-Tz) from 2013
outlines the services that are expected to be provided in the public health facilities. The
NEHCIP-Tz encompasses those interventions with the greatest impact on Tanzania’s burden
of disease, which ideally should be provided across the levels of the health care system. The

32
package also defines which support systems (capacities of human resources, essential
medicines and health products, etc.) should therefore be available. Further refining and
detailing of the NEHCIP-Tz will take place during the HSSP IV period taking into account
provisions made in the Basic Standards for Health Facilities documents (Volumes 1-5) and
the managerial support needed. Core interventions, which can be provided with available
resources, will be identified. The refined NEHCIP-Tz will feed into the formulation of the
Minimum Benefit Package of the Single National Health Insurance. This essential package
will guide interventions and activities to be prioritised, staff to be engaged, medicines to be
procured, etc. Based on further increase of funding for the health sector, the package can be
widened over time.

5.3.2 Community Health

Strategic Direction: Revitalising Community Based Health Care, increasingly supported by

professional Community Health Workers, will ensure that essential health promotion, health
protection and prevention activities are addressed in partnership with communities, with a
high rate of return on investments. The Community-based health programme aims to reduce
the pressure on facility-based care through enhancing healthy living at households, in schools
and work places.

Health is affected by both the home and work environment. Community engagement in
health is crucial to addressing the social determinants of health. Even before the Alma Ata
Declaration in 1978, Tanzania promoted community-based health services, generally based
on voluntarism. Tanzania will revitalise community-based health activities with employed
basic cadres incorporated in the health system, providing quality and continuity of services.
By the end of the HSSP IV period it is intended that the Community-Based Health
Programme will cover 50% to 60% of communities, focusing on under-served and remote
communities.

Formalisation and integration of CHWs and their training

The Community-based Health Programme will be finalised, with prioritisation of the
underserved regions. A cadre of Community Health Workers will be formalised, their role in
providing health promotion, preventive and curative services will be defined, and a standard
remuneration scheme established. Their training curriculum will be finalised accordingly,
and training and deployment will take place as part of the Human Resources for Health
planning. A clear plan for transitioning from existing CHW schemes involving health
volunteers to a professional CHW cadre linked to the local health systems will be developed.
However, over the HSSP IV period both formalised and non-formalised CHW will continue to
operate as the formal CHW cadre will be not large enough to replace the non-formal.
Untrained Health Facility Attendants shall be formalised based on an approved curriculum
and deployed at primary and other health facilities according to the needs. The same cadre
entry point shall be utilised for formalising the CHW and the Para Social Attendant.

Communities will be responsible and will take the lead in pursuit of community-based health
services. Local resource mobilisation to support this is necessary, both from the local
community and as part of the Comprehensive Council Health Plans. There will be close
collaboration with NGOs and Community-Based Organisations involved in health promotion
and health protection or care for vulnerable groups, to incorporate their activities into the
broader Comprehensive Council Health Plans.

33
Health facilities will be responsible for coordination and support to health promotion and
community-based health initiatives. Monitoring of community-based activities will be
integrated in the HMIS and in the sector-wide Monitoring and Evaluation plans.

Health action in schools

The National School Health Programme (NSHP) will be strengthened, as it is important to

capacitate youth towards positive health actions. It will contribute to more adolescent-
friendly health and social welfare services. The policy guideline and strategy for the NSHP
will be revised to include positive behaviour change for prevention of both communicable
and non-communicable diseases, promotion of healthy life styles, promotion of sexual
health and rights, including the importance of healthy eating and physical fitness. Capacity
building of school health coordinators will take place to improve the leadership and quality
of school health promotion as part of the integrated health promotion packages. The NSHP
is coordinated and implemented jointly with the Ministry of Education and Vocational
Training (MOEVT). The guideline and strategy for the NSHP will be disseminated and
monitored during the HSSP IV period.

Intensified Health Communication

Health Communication (Social and Behaviour Change Communication) aims to increase

health literacy, promote positive health behaviour and adoption of appropriate coping
strategies. A strategic focus will be promoting the devising of life-long health learning
ventures among established institutions, organisations, forums, mechanisms (e.g.,
household prayer groups, pre-schools, schools, ceremonies, events, clubs, mosques,
churches, meetings, etc.). The sector will use of a broad range of communication channels
and processes including interpersonal (education and counselling), electronic (television,
radio, video, telephone and internet), print (posters, pamphlets, leaflets, billboards) and
traditional means of communication (songs, drama, poems). New information media (mobile
text messaging and internet social media) will be harnessed to empower communities with
knowledge and skills to effect behavioural change. MOHSW will strengthen and oversee
information, education and communication processes and actions for better social
mobilisation, community empowerment and advocacy to promote health among
communities. The ministry will make a viable website to show meaningful communication.

5.3.3 Council Health Services

Strategic Direction: Council Health Services will constitute the backbone of the health
services. These services will provide the National Essential Health Care Intervention Package
(NEHCIP-Tz) while guaranteeing quality (3-star rating) and transparency (social
accountability). Increased trust will sensitise the population to enrol in the Single National
Health Insurance and take part in management of Council Health Services.

The Council Health Services constitute the backbone of health care in the country, especially
in rural areas where the number of private health providers is limited. Dispensaries, Health
Centres and First Level Referral Hospitals provide the National Essential Health Care
Interventions Package. These services address common health conditions, and refer
complicated cases to higher levels. Mentoring and technical support by the Council Hospital
and Council Health Management Team (CHMT) will contribute to quality improvement of

34
primary health care facilities. As mentioned before (under quality, section 5.2), all primary
health care facilities, public and private, will be assessed and will be facilitated to develop a
quality improvement plan to reach the minimum standard level of services (3 Star Rating
and beyond), starting in identified BRN regions, spreading all over the country in the HSSP IV
period.

The CHMT will oversee administrative and governance issues of the Council health services.
The Council Social Welfare Officer is a core member of the CHMT. Under the CHMTs a
Technical Committee (TC) shall be put in place. In the TC, those who will participate include
core CHMT members, co-opted members and also new members who will be given
responsibility to manage areas that are not currently contained in CHMT. The TC has a duty
to oversee and discuss the technical and professional issues on improving quality of health
promotion, preventive, curative and rehabilitative health services at the Council level.

The Council or District Hospitals provide the first level of referral services for primary health
care facilities, providing medical care for common health problems and emergency care for
obstetrics and surgical cases. These services are part of the NEHCIP-Tz.

Integrated and evidence-based health planning and decision making at LGAs

The CHMTs will play an important role in evidence-based planning and decision-making,
through the Comprehensive Council Health Plans and support to lower level health facility
plans. PMO-RALG with support from MOHSW will continue development and integration of
planning, budgeting and reporting tools, using ICT systems. By the end of the HSSP IV period,
100% of the Councils will have approved annual plans.

The planning will be inclusive, bringing on board all relevant actors in health care in local
councils (including public and private first line health facility managers) and incorporating
support from disease control programmes and (inter)national NGOs. The TC will do the
groundwork of data analysis and epidemiological profiling to feed into the CCHP process.
Parallel programming and implementation in the health sector will be discouraged and
instead integrated capacity-building in planning, management and continuing support will
be promoted. Councils will be empowered to withhold operating licences for NGOs not
adhering to defined standards of collaborative action.

Decentralisation of financial management to the facility level

Social accountability is a priority in the health sector. Council Health Service Boards (CHSBs)
and Health Facility Governing Committees (HFGCs) will be revitalised to oversee and co-
manage health services and demand accountability on the use of resources, including
finances, at the health facility level. By the end of the HSSP IV period, 80% of the HFGCs will
be fully functional.

Revised Terms of Reference and regulations will guide these bodies and their activities. The
Councils will decentralise more powers to the lower level Health Centres and Dispensaries
and empower local staff to manage health services. The health facilities will produce their
own plans and budgets in coordination with HFGCs. Primary health care facilities will open
their own bank accounts (decentralisation of financial management) and will increasingly
manage their own income and expenditures, including procurement of medical supplies and
commodities, primarily through the Medical Stores Department. The private sector will
contribute to the availability of medicines and supplies through prime vendors supplying
MSD as well as through direct supplies to health facilities, contracted at the regional level to
serve LGAs, ensuring checks and balances that will focus on value for money and quality.

35
A system of performance management and results-based financing will provide incentives
for better service provision at the grassroots level, both for individual health workers and for
health facilities.

Partnership with Private Providers

Private providers will be encouraged to contribute to service provision and will find a level
playing field as a result of the certification/accreditation system and the fee for services
system (health insurance system). In targeted regions, 25% of public health facilities will
optimise PPP Forums to engage the private sector in service provision. (See Section 7.2
Public Private Partnership.)

5.3.4 Regional Referral Level

Strategic Direction: Regional Referral Hospitals will serve as centres of medical excellence
and referral in the Regions, and as the hubs for technical innovation to be disseminated to
lower levels.

The Regional Referral Hospitals (RRHs) will continue the improvement of quality of care and
management of general and specialised medical care (focussing increasingly on specialised
care). In response to the demand for referral services at the regional level, the Government
gazetted ten faith-based voluntary agency hospitals as Referral Hospitals at the Regional
Level (RHRL). A Memorandum of Understanding will be finalised between the Government
and the owners of these facilities to guide the partnership arrangements.

Electronic medical records and e-health expansion

The RRHs will strive to achieve improved clinical management and referral through the use
of Information Communication Technology (ICT). Hospitals will improve the ICT
infrastructure and connectivity for patient recording, aggregation of patient data and
administration. By the end of the HSSP IV period, 80% of the RRHs will have electronic
patient management systems in place.
The RRHs will improve and scale up e-health and connect to the lower health facilities for
better referral, while ensuring inter-operability across the nation. Regional Referral Hospitals
will establish a forecasting and monitoring system of essential medicines and supplies
through better supply management systems.

SOPs, clinical audits and mentoring

Clinical guidelines and SOPs for clinical management of patients will be reviewed, updated as
necessary and disseminated to all RRHs and the Regional Technical Committee. Medicines
and Therapeutics Committees will establish an internal monitoring and evaluation system
using the computerised hospital information management system, and clinical and death
audits will be institutionalised. The performance management system will provide incentives
to improve and sustain quality of care.

Further capacity building for improved customer care will be provided to all health
professionals in RRHs. Through Quality Improvement Teams (QITs) and Work Improvement
Teams (WITs) assessments on adherence to quality standards will be carried out. There will
be quarterly mentoring and coaching of clinical management of patients.

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Leadership, planning and resource management capacity

RRHs’ management will be improved through capacity building in governance, leadership,

planning, financial management, and resources management including planned preventive
maintenance. Hospitals will prepare and implement annual Comprehensive Hospital
Operating Plans, which will be monitored quarterly.

Improvement of governance and leadership at RRHs will be stimulated through Regional

Hospital Health Services Boards (HSBs) with community representation to which the hospital
management will be accountable. The functions of the boards will be laid down in legislation
and members will be trained in monitoring and evaluation. The Ministry established a
special project to strengthen the managerial capacity of RRH Management Teams and
Health Services Boards for next five years. By the end of the strategic period all RRHs will
have functional HSBs in place.

Regional Health Management Teams (RHMTs) will conduct supportive supervision and
provide technical backstopping to RRHs and will perform data quality audits. The Regional
Social Welfare Officer is a core member of the RHMT. The RHMT shall oversee
administrative and health governance issues at the region. Under the RHMTs a Technical
Committee shall be put in place. In this committee core RHMT members, co-opted members
and also new members will take place who will be given responsibility to manage areas that
are not currently contained in RHMT. Competency in epidemiological analysis shall be a
requirement for effective technical functionality of this technical team. The TC has duty to
oversee and discuss the technical and professional issues on improving quality of health
promotion, preventive, curative and rehabilitative health services to LGAs and the region as
a whole.

5.3.5 Zonal and National Level, including International referral

Strategic Direction: Expansion of the number of Zonal and National Hospitals will enable
referral of complicated cases countrywide, and will reduce the necessity for international
referral.

Zonal Referral Hospitals

Zonal Hospitals will provide specialised and super-specialised care to patients referred from
Regional level hospitals. There will be improvement of quality of care in Zonal hospitals by
ensuring these hospitals have adequate skilled Human Resources for Health as per
established staffing levels, modern medical equipment and infrastructure. Currently there
are five Zonal referral hospitals, both public and private, serving the Lake (Bugando
Hospital), Northern (Kilimanjaro Hospital, Southern Highlands (Mbeya Hospital) and Eastern
Zones (CCBRT Hospital). To further enhance accessibility of specialised services to all, the
MOHSW will establish a Zonal referral hospital in Mtwara to serve the population in the
Southern Zone. Furthermore, in collaboration with the private sector, the MOHSW will
establish another Zonal hospital in Dodoma for the Central zone and if funds allow another
one will be established for Kigoma (Western Zone). The MOHSW will continue to deploy
specialist doctors to these hospitals. Hospital Management Teams and specialists from Zonal
hospitals will provide outreach services and conduct clinical supportive supervision to lower
level facilities in their respective Zones.

37
Zonal Hospitals will strive to achieve improved clinical management and referral through the
use of ICT. Hospitals will improve the ICT infrastructure and connectivity for patient
recording, aggregation of patient data and administration. By the end of the HSSP IV period
all Zonal hospitals will have electronic patient records in place.

Hospitals will establish a monitoring and evaluation system using the computerised hospital
information management system. The government will continue to equip Zonal hospitals
with necessary functional medical, diagnostic equipment and supplies. The Hospital Health
Services Boards to which the hospital management will be accountable, will guide
improvement of governance, accountability and leadership at Zonal hospitals.

National Level, including International referral

National Hospitals including Special Hospitals will provide super specialised care to patients
referred from Zonal and Regional level hospitals. There will be improvement of quality of
care in National hospitals by ensuring these hospitals have adequate skilled human
resources for Health (super specialists and specialists) as per established staffing levels and
scheme of service, modern medical equipment and infrastructure. Currently there are five
such hospitals, one national level Hospital (Muhimbili National Hospital (MNH) and four
special hospitals (Muhimbili Orthopedic Institute, Ocean Road Cancer Institute, Mirembe
Mental Health Services Hospital, Kibong’oto Infectious Diseases Center). The Government
aims to reduce the cost incurred in treating patients who are referred abroad due to lack of
infrastructure and expertise in the country. PPPs should be used in areas of diagnostics,
treatment and optimisation of existing expertise. The Cardiac centre under MNH will be
upgraded to a fully-fledged institution for treatment of cardiac conditions.

5.4 Health Service Provision by type of Service

5.4.1 Health Promotion

Strategic Direction: Invest in health promotion interventions that give emphasis to multi-
sectoral approaches in addressing the preventable causes of disease, disability and
premature deaths in all population groups throughout the course of life.

The MOHSW and partners have formulated the National Health Promotion Policy Guideline
(2014) and Strategic Plan of Action (2015 – 2020) according to the Ottawa Charter for Health
Promotion (1986), enabling people to increase control over, and to improve, their health.
The ultimate outcomes of effective health promotion interventions include increased
community health awareness, participation and empowerment, and other positive changes
in health-related behaviours. The MOHSW will ensure better coordination of advocacy,
social and behavioural change communication across different initiatives, programmes and
interventions. To do so, the MOHSW will provide national standards and guidelines for
designing, development and delivery, monitoring and evaluation of health communication
interventions. The MOHSW will also establish a national resources centre for health
communication. This resources centre will produce and archive integrated health promotion
packages, which include paper, audio-visual and e-health materials.

To strengthen community capacity for health promotion, the MOHSW, through the
implementation of a Community Health Strategy, will ensure effective active community
engagement in the design, planning, implementation monitoring and evaluation of health
promotion interventions, and linkage with social welfare, nutrition, and environmental

38
health. In addition, the MOHSW will oversee capacity building for and professionalisation of
CHWs to plan, implement, monitor and evaluate health promotion interventions at the
community level. The MOHSW also recognises the contribution of health promotion in
improving young people's health and well-being, and subsequently in the adult life;
therefore, it will invest in the National School Health Program for better health and
education outcomes (as referred to in section 5.3.2).

5.4.2 Nutrition Services

Strategic Direction:
The health sector, in collaboration with partners, will accelerate nutrition interventions, with
emphasis on pregnancy stage and the two first years of life (1000 days).

The Essential Nutrition Action Approach (ENA) aims to reach at least 80% of caregivers
through health services. The percentage of underweight children will reduce from 16%
(TDHS 2010) to 11% in 2020. The percentage of stunting children will reduce from 42% to
27% in 2020.

The sector will work within the institutional framework for implementation of nutrition
services involving nutrition experts at national, regional and council levels, to sustain
nutrition service delivery. This will institutionalise nutrition interventions in the country. The
MOHSW will oversee the revision of the Food and Nutrition Policy of 1992, develop its
implementation strategy (2015/1616 – 2025/26) and develop and implement a National
Nutrition Action Plan for 2015 – 2020 based on the outcomes of the National Nutrition
Survey 2014.

MOHSW and MDAs will review and update guidelines to address maternal and infants and
young child feeding, management of acute malnutrition, control of micronutrient
deficiencies and healthy eating and lifestyle issues as needed. A pool of nutrition
professionals is sustained through skill based in-service and pre-service training programs
integrated in existing curricula.

The health and social welfare sector will promote appropriate maternal, infant and young
child feeding practices in households and in communities and will advocate towards
reducing food insecurity among households. More attention will be paid to strengthening
compliance to exclusive breast feeding and infant and young child feeding practices, and
promoting hygiene and sanitation practices. Strategies for control of micronutrient
deficiencies will be integrated in the Community Health Programme.

At the health facility level, nutrition services are integrated within RMNCAH using already
skilled professionals. Routine provision of nutrition counselling and essential vitamins and
micronutrients to pregnant and lactating women and children under the age of five-years
will be strengthened.

The MOHSW will strengthen the capacity for management of acute malnutrition. Children
with nutrition disorders will be identified, investigated for underlying diseases, and, when
necessary, treated or referred for nutrition rehabilitation and family support. Social welfare
services will be provided where necessary. The MOHSW will ensure regular provision of
nutrients for supplementation, fortification and promote dietary intervention for control of
micronutrient deficiencies.

39
Through integrated Health Promotion interventions, health workers will encourage people
to shift to healthy diets and avoid unhealthy foods (high in carbohydrate, fat, sugar, and
salt). Through campaigns, the MOHSW will intensify awareness creation and public
sensitisation on life-style related illnesses, to prevent behaviour risk factors contributing to
becoming overweight or obese; these campaigns aim to reduce hypertension risk factors,
coronary heart disease, stroke, diabetes and some forms of cancer.

5.4.3 Reproductive, Maternal, Newborn, Child & Adolescent Health

Strategic Direction: The health system will be strengthened to provide quality services which
will contribute to achieving the goal of ending preventable, maternal, newborn and child
deaths and ensure universal access to sexual and reproductive and adolescent health
services.

Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) will continue to
be a priority for the country. Maternal and newborn health has been identified as one of the
Key Result Areas (KRAs) under BRN. BRN has prioritised interventions in regions with high
mortality and morbidity, but during the five years of this strategic plan the activities will
spread from these initially selected regions to the whole country. By the end of the HSSP IV
period, quality RMNCAH services will be within reach of the whole population in the country.

RMNCAH is fully integrated in health services at the primary level. Improving these services
has an impact on most health system strengthening pillars, e.g., the quality of HRH, ensuring
adequate commodities, including essential medicines and vaccines, supplies, equipment,
infrastructure, and the referral system. Strengthening RMNCAH therefore is not a vertical
programme and will function as an engine for improving the broader range of health
services.

Community health programmes will contribute to improved community mobilisation,

bringing services closer to the population (e.g. family planning), advocating utilisation of the
available services (e.g. ANC, skilled birth attendance) and stimulating families to seek early
medical assistance, e.g. in outreach activities, or use of m-health supported by text message
campaigns. The health sector will collaborate with other stakeholders, e.g., the Ministry of
Gender, Women and Children and the MOEVT in achieving greater accessibility of services.

Ensuring accountability and transparency for RMNCAH services is part of overall health
systems strengthening. Maternal and perinatal death surveillance and response will be
implemented countrywide to assess quality of care, to perform critical incident analyses, and
to identify opportunities for improvement. By the end of the HSSP IV period, at least 75% of
maternal and perinatal deaths will be evaluated, leading to actions for improvement of
services.

Best practices in maternal, newborn and childcare shall be monitored, documented and
shared for scaling up. The RMNCAH scorecard will be disseminated countrywide at National,
Regional and Council levels and used to improve accountability, transparency and monitor
progress in the implementation of RMNCAH interventions. The use of data for planning and
decision-making will improve as part of HMIS strengthening. Innovative approaches to HR
motivation and retention in all vital services will be encouraged and brought to scale.

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5.4.3.1 Maternal and Newborn Care

By the end of the HSSP IV period, Skilled Birth Attendance will have increased to over 80%.
The initiatives will result in a reduction of maternal mortality ratio from 432 (Census 2012)
to 292 per 100,000 live births and neonatal mortality rate from 21 (IGME 2012) to 16 per
1,000 live births.

The health sector will continue to expand the provision of quality services during pregnancy,
childbirth and the post-natal period. Emphasis will be on the provision of Basic Emergency
Obstetric and Newborn Care (BEmONC), and Comprehensive Emergency Obstetric and
Newborn Care (CEmONC), starting in strategically located areas (along the lines of BRN), to
address the needs of larger populations, and in facilities with high burden of RMNCAH
problems. By 2020, 70% of primary health facilities will provide BEmONC; 50% of health
centres and 100% of hospitals will provide CEmONC.

Community awareness activities will reach every household in the country, informing
pregnant women on prevention of low birth weight through proper feeding, convincing
clients to make use of available ANC and delivery services. The ANC 4 visits coverage should
reach 90% by 2020. Postnatal and newborn follow up at the household level will be
encouraged to identify problems and provide timely referral. Postnatal care will reach 80%
in 2020. Innovative approaches like m-Health, community level emergency transport
systems will be encouraged to support CHWs. The link between community health worker
and health facility will be strengthened to ensure a continuum of care down to households
as needed.

Clinical guidelines for maternal and new born care will be adapted, disseminated and
monitored. Capacity building of human resources for RMNCAH services will continue.
Review of legislation and regulations will take place to enable cadres to perform required
services through task shifting, e.g.in anaesthesia.

The sector will facilitate supply of essential medicines, other commodities and equipment.
Regional Satellite Blood Bank Services will be established to increase availability of blood
close to CEmONC centres in the country. The National Blood Transfusion Service will be
strengthened for providing quality assurance to the regional satellite blood banks. The
referral system will be fully operational, to guarantee that pregnant women get the services
they need.

As with RMNCAH, Prevention of Mother to Child Transmission (PMTCT) of HIV will be fully
integrated into health services and postnatal care services will be provided in all health
facilities. By 2020 all (100% of) eligible patients will receive PMTCT. Subsequent HIV testing
after first testing will be strengthened as per protocols (e.g., second test for pregnant
women at ANC, after delivery, and after breastfeeding).

5.4.3.2 Child Health

Under-five mortality will reduce from 54 (IGME 2012) per 1,000 to 40 per 1,000 and infant
mortality will reduce from 45 (census 2012) per 1,000 to 25 per 1,000 in the HSSP IV period;
and the stunting status will improve from 42% (TDHS 2010) to 22%.

The sector will continue to provide quality child health services to further reduce child
mortality. Prevention of major causes of child death, such as pneumonia, diarrhoea and

41
malaria, will be addressed and health seeking behaviour will be stimulated (also for
congenital disorders). Care of newborn children at delivery and post-delivery care will
receive focused attention to cut down on day-one and week-one mortality, eventually
cutting down on overall neonatal mortality. Community health workers will provide
information, and encourage uptake of vaccines and other preventive interventions. Through
the Community-Based Health Programme, the health sector, in collaboration with other
sectors, will promote nutrition specific and sensitive practices (see below under section 5.5).

Access to treatment will be improved by scaling up the Integrated Management of

Childhood Illnesses (IMCI) protocols. This will include capacity building of health workers by
distance learning, provision of essential medicines, equipment and supplies. The
achievements in the immunisation services will be sustained in line with the Global Vaccine
Action Plan Goals with coverage over 90% in 90% of all districts. These goals include polio
eradication, elimination of neonatal tetanus, measles, rubella and congenital Rubella
syndrome, and introducing new vaccines to prevent other vaccine preventable diseases in
the country. Strategies will be instituted to ensure accessibility and utilisation of the
immunisation services using the Reach Every Child approach by provision of daily
immunisation services at health facilities and strengthened outreach services in hard to
reach areas.

Early infant diagnosis of HIV at eight weeks and further tests as per protocol for HIV exposed
children or per medical indication will be integrated in different settings (e.g., child clinic,
immunisation, growth monitoring). Early infant male circumcision will be considered as a
potential sustainability plan for Voluntary Medical Male Circumcision (VMMC).

5.4.3.3 Adolescent Health

Adolescent Fertility Rate will drop from 118 to less than 100 pregnancies per 1,000 women
and HIV prevalence in girls will drop from 2.0% to less than 0.8% in 2020.

Adolescent Friendly Sexual and Reproductive Health Services (AFSRHS) will be expanded.
Focusing on adaptation and use of Adolescent friendly guidelines and standards, demand
creation and utilisation of AFSRHS, adolescents and youth will be encouraged to access
VMMC, STI diagnosis and treatment, condoms and other contraceptives, and HIV testing and
counselling services through age-appropriate IEC, peer education and mobilisation of young
people. Risks of multiple sexual partners, unprotected sex and predisposing factors such as
alcohol and substance abuse, unsafe injections and unsafe blood shall be key messages in
IEC and peer education. VMMC will also be considered as an entry point to engaging with
adolescent boys more broadly on ASRH and HIV-related health promotion, preventive and
treatment interventions and services. Peer education will be encouraged for in and out of
school adolescents, in partnership with other Ministries and NGOs. The education shall
target transfer of knowledge, skills and, for the sake of eliminating stigma, positive peer
pressure, positive socio-cultural appeals, applied in a rights-based approach will be utilized
to shape attitudes (zero-tolerance to stigma). Other aspects of adolescent health will also be
addressed through linkages with other programmes, including HIV, immunisation, mental
health services and school health services as avenues to expand health services and increase
adolescents’ access and use of health services.

Health workers will become advocates of AFSRHS. Available adolescent-friendly RHS

education and service guidelines will be disseminated to health workers. Supervisors and
health care providers will receive training on AFSRHS. The utilisation of AFSRH services by
adolescents should double in the HSSP IV period, with, for example, a clear impact on

42
incidence of HIV among girls or STIs among adolescents. To address the deficiency in data
and improve accurate estimations of the disease burden in the adolescent population, data
disaggregation in the HMIS will be a priority during HSSP IV.

5.4.3.4 Family Planning

The uptake of FP methods in the country will increase significantly by 2020. Contraceptive
Prevalence Rate (married women 15-49) will increase from 27.4% to 60% in 2020 and
Adolescent Fertility Rate (under 20) will reduce from 11.6% to less than 10% in 2020.

Family Planning (FP) using modern methods will continue to receive high priority to delay
the age of first pregnancy, to space birth, and to limit the number of children to be born to
the women’s choice. Barriers to access of FP services, e.g., limited provider capacity,
misinformation, sometimes stock-outs of commodities will be removed. The number of FP
acceptors will increase through demand creation on a rights-based approach that ensures
information and choices are optimised through peer learning. Here also, as in the HIV
programme, positive peer pressure and positive socio-cultural appeals shall merit attention
for effective demand creation. Mass media campaign and community outreach services
(providing commodities) will be enhanced to improve accessibility for all adolescents and
adults in need of services.

Capacity building of health care providers will continue to provide the full range of FP
methods to ensure high quality service delivery. FP services will continue to be integrated
with other RMNCAH services. Opportunities like counselling on FP at ANC, PNC, and
immunisation clinics will be exploited.

5.4.3.5 Violence against Women and Children

Prevention of and response to violence against women, adolescents and children will get
more attention through demand creation in the community and capacity-building of health
staff and ensuring services and support are provided to the survivors of violence. Within the
Local Government Authority’s jurisdiction, collaboration will be built with other sectors to
strengthen or establish One Stop Centres catering for the treatment, protection, legal,
prevention and rehabilitation needs of women and children affected by violence (see
Section 7.3 and section 5.7). Current pilots in collaboration with Police, social welfare and
other government entities and NGOs will be expanded.

5.4.4 Communicable Diseases

Strategic Direction: The health system will maintain the high level of performance of Disease
Control Programmes; reduce morbidity and mortality caused by infectious diseases while
increasing efficiency through improved integration of activities.

Disease Control Programmes, e.g., malaria, tuberculosis and HIV/AIDS require specific
knowledge and skills in some areas, e.g., vector control, contact tracing, diagnostics and
treatment regimes. In other areas, common knowledge on health promotion, disease
prevention, laboratory diagnostics or supervision, monitoring and evaluation is applicable. In
the HSSP IV period, emphasis will be on maintaining the high level performance of control of
communicable diseases, while reducing costs considerably through integration of services.

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5.4.4.1 Malaria

The country will continue the successful reduction of malaria mortality and morbidity
through preventive and curative measures. The overarching goal is to reduce the average
country malaria prevalence from the current 10% to 5% by 2016 and further down to less
than 1% by 2020. Priority will be given to areas of endemic malaria transmission.

Community sensitisation will result in 95% of households showing positive behaviours with
regard to malaria prevention and with regard to early health seeking for suspected cases.
Council health services will reduce the transmission of malaria by scaling-up and maintaining
effective and efficient vector control interventions. By 2020 at least 85% of the population
living in all transmission settings and control stages, will have access to Long Lasting
Insecticidal (LLIN) within their households. The Councils in endemic areas will consolidate
and expand Indoor Residual Spraying in epidemiologically and operationally suitable areas,
covering at least 20% of house structures in the country by 2020. The sector will implement
larviciding interventions in selected urban areas where breeding sites are few, fixed, and
findable, in order to reduce the larval density in the selected sites by 75% by 2020.

Primary and referral health services will prevent the occurrence of severe morbidity and
mortality related to malaria infection through promotion of universal access to appropriate
early diagnosis and prompt treatment and provision of preventive therapies in vulnerable
groups. The health sector will provide universal access to appropriate, quality and timely
malaria diagnosis to at least 80% of people with signs and symptoms of malaria by 2020.
Health services will provide universal access to appropriate, quality and timely treatment to
at least 80% of people who have malaria by 2020.

The country will ensure that commodities used in malaria patient care and prevention are
consistently safe, quality assured and available at 100% of the points of care by 2020.

5.4.4.2 HIV/AIDS

By 2020, the coverage of the national response to HIV and AIDS will have improved to
ensure that 90% of all people living with HIV know their HIV status, and 100% of pregnant
women eligible for PMTCT will receive treatment in 2020. The HIV care and treatment
programme will improve coverage in at-risk children and adolescents so that overall, 90% of
all people diagnosed with HIV are followed and receive timely and efficacious highly active
antiretroviral therapy, and 90% of all people receiving the antiretroviral therapy will attain
sustainable viral suppression.

During the HSSP IV period, health experts will continue implementing HIV and AIDS
interventions to further reduce the incidence of new cases of HIV infection and provide
access to HIV prevention, care, treatment, and support services. A special focus will be on
geographical areas characterised by higher than national average HIV prevalence, high
burden in terms of number of People Living with HIV, increasing prevalence over several
years, and relatively lower performance on key HIV and TB indicators. Maintenance activities
will continue in other areas, but active scale up will be the approach of choice in the
prioritised geographical areas.

HIV prevalence in women is higher than in men in all age groups, but differentials are the
highest among young women and girls, reflecting the strong gender element in risks of and

44
vulnerability to HIV infection in the country. Prevention is a priority, especially in vulnerable
groups like adolescent girls. Awareness about HIV risks and prevention of sexually
transmitted infections in adolescents is key, e.g., through access to condoms. Other high-risk
groups like people using drugs, sex workers and men who have sex with men will have high
priority for preventive activities.

VTC will continue as an integral part of adolescent friendly health services. VMMC activities
will be stepped up as well.

The Government in collaboration with partners and stakeholders will scale up quality anti-
retroviral therapy (ART) services for adults, adolescents, pregnant and breastfeeding women
and children through decentralised and integrated care and treatment services, as well as
improved monitoring of response to ART and retention in care. The limited access to services
by children, particularly for TB diagnosis, early infant diagnosis for HIV and paediatric ART,
will be prioritised through stronger integration of HIV care and treatment into the RMNCH
platform. Investments will be targeted to ensure improved access to optimum care and
treatment for HIV exposed babies. Co-infections and co-morbidities in people living with HIV
(PLHIV) will be addressed while community-based HIV and AIDS services will be
strengthened, in particular, follow up systems and linkages between health systems and
communities for people in care and treatment. The planned joint TB and HIV program
reviews, supervisory visits, joint planning and training activities, co-location of ART, TB and
RMNCAH services (“one stop shop”) will facilitate service integration and promote efficiency.
There will be more attention for reducing stigma by providing integrated care and by
counteracting acts of discrimination in order to enable PLHIV to live a normal life. In close
collaboration with TACAIDS, the campaign against multiple sex partners and unsafe sex
practices shall be intensified.

The National Blood Transfusion Service (NBTS) will continue to play the core role of
mobilising and recruiting blood donors to ensure increased availability and access to safe
and quality blood and blood products, preventing HIV transmission from blood donors to
recipients.

The national response to HIV and AIDS will benefit from health system strengthening, like
Quality Improvement programmes, integrated procurement and pharmacovigilance and
laboratory services. Surveys & studies, surveillance, evaluation and research will
complement routine, age-disaggregated HMIS data and information collection for improved
HIV and AIDS programming and policy decisions.

5.4.4.3 Tuberculosis and Leprosy

By 2020 the Tuberculosis Case Detection Rate will reach 72% and the TB Cure Rate will be
above 90%. By 2020, less than 7% of new leprosy cases will have Grade 2 disabilities, and
less than 2% of new leprosy cases will be children.

The health services will scale up active case finding measures in addition to routine case
detection. The sector will concentrate on finding and treating TB in key affected populations
(elderly, prisoners, diabetics). It will improve treatment of patients.

The country will strengthen integrated childhood TB management in health facilities,

including contact tracing. It will integrate childhood TB and TB-HIV services in maternal and
child health care settings, including PMTCT services in the country. Collaboration between
TB and other programmes (HIV, RMNCAH) will intensify reaching more PLHIV, families, and

45
communities. TB is a special risk in the mining sector. TB screening and active case finding
among mine workers, their families and surrounding communities will be stepped up. The
Community-Based Health Programme will improve health seeking behaviour among miners,
their families and surrounding communities.

The laboratory system will be improved and 50% of underperforming diagnostic centres will
be brought up to standard. Health services will expand the use of chest X-ray and digital
imaging in the diagnosis of tuberculosis. The health sector will establish an electronic case-
based recording and reporting system for both TB and Leprosy diseases that is integrated
with DHIS and will improve the TB surveillance system’s ability to accurately measure the
burden of TB disease.

Multi Drug Resistant TB (MDR-TB) will be tackled with new TB diagnostic technologies for
testing of presumptive MDR-TB cases. The health sector will improve specimen referral and
feedback systems between diagnostic centres and TB culture laboratories. MDR-TB
management services for early initiation of treatment and care will be decentralised, while
maintaining Kibong’oto Infectious Disease Hospital as a centre of excellence for TB services.

Tanzania will reduce new leprosy cases with disability grade 2 from 0.7 to 0.3 per 100,000
population by early case finding and treatment of leprosy patients. Through community
involvement and participation TB, TB-HIV and leprosy prevention, care and treatment will
improve.

5.4.4.4 Neglected Tropical Diseases

By 2020, transmission of Neglected Tropical Diseases (NTDs) targeted for preventive

chemotherapy such as Onchocerciasis, lymphatic filariasis and trachoma will be interrupted
in over 90% of the endemic districts.

NTDs are often associated with life-long disability and very serious chronic social and
economic consequences. More than 10 NTDs affect rural poor communities and contribute
to increasing poverty in the affected communities.
The health and social welfare sector will scale up access to interventions and treatment of
neglected tropical diseases. Community structures, including schools, will promote health
and behavioural change for the prevention, control and elimination of these diseases.
The health services will conduct Mass Drug Administration (MDA) in communities for
lymphatic filariasis, onchocerciasis, trachoma, soil transmitted helminthiasis and
schistosomiasis. For morbidity alleviation, specialised treatment will be available (surgery for
hydroceles and trachomatoustrichiasis, and lymphoedema management).

The country will work to improve the detection and management of other NTDs including
Human African trypanosomiasis, rabies, and plague. Relevant interventions and diseases
diagnosis will be improved and reporting integrated into the national and council health
information systems.

NTDs reporting systems will be integrated with the surveillance and epidemic preparedness
efforts like the IDSR. Operations research will be conducted to ascertain the prevalence of
tick borne relapsing fever, cysticercosis, and taeniasis. Impact assessments and surveillance
of MDA programmes will be conducted to ascertain prevalence trends and break of
transmission cycles where relevant.

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5.4.5 Non Communicable Diseases

Strategic Direction: The country will focus on community-based prevention, health

promotion, screening and early treatment as well as rehabilitation. Activities will be
integrated in health services and not as new vertical programme.

During the HSSP IV period, the country will prevent the further increase of overweight (26%),
high blood pressure (26%) and if possible revert the trend of lifestyle related risk factors and
ill health conditions.

Strengthening the prevention and treatment of Non-Communicable Diseases (NCDs) is

currently a major challenge in this country. The health sector recognises the need for action
to reverse the trend of increasing NCDs due to changing lifestyles and ageing of the
population. The MOHSW will update the National Multi-sectoral Plan for Non-
Communicable Diseases (NCDs), with attention to health promotion, prevention and care.
Strengthening NCDs services in regular health services will be a priority, avoiding new
vertical approach in this cluster of health conditions. Health care workers will be trained on
NCD management. The STEPS Survey on NCD risk factors conducted in 2012 shows the
priority areas; the survey will be repeated for trend analysis.

The health sector will improve health service provision for older people (≥ 60 years) in public
health facilities. The MOHSW will develop a strategic plan for the provision of equitable
health services for older people and will develop clinical guidelines in the area of geriatric
medicine. It will facilitate the inclusion of specific training in the curriculum of health
professionals and the introduction of postgraduate training in geriatric medicine.

5.4.5.1 Mental Health and Substance Abuse Disorders

The country will develop and implement a national policy and plan in line with the 2013-
2020 global mental health action. This will include mental health promotion, prevention,
treatment and recovery services. As much as possible mental health services will continue
to be integrated in health services and community programmes, through better guidance
and tools for health care professionals. Collaboration with relevant sectors will be pursued in
dealing with substance abuse disorders (alcohol, drugs, tobacco) in terms of prevention,
treatment, and social and physical rehabilitation. Stigma reduction for people with mental
illnesses will be part of health promotion programmes.

Where necessary, legislation will be put in place. The country will oversee full
implementation of existing treaties such as the WHO Framework Convention on Tobacco
Control by putting in place appropriate regulations for legal enforcement.

5.4.5.2 Cancer

By 2020, 80% of women between 30 and 50 years will be screened for cervical cancer.

The MOHSW will develop national strategies and programmes for cancer prevention and
control. The health sector will scale up cancer prevention, cure and care services. Attention
will initially be given to public awareness campaigns, to increase the demand for screening
and early detection and treatment. The MOHSW will also stimulate community involvement
in home based care and palliative care for patients.

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The health sector will scale up the prevention and response to reproductive organs cancers.
There will be information campaigns to inform the public about the risks. Capacity building
for screening and treatment for reproductive organs cancers (cervical, breast and prostate)
will take place. By 2020, reproductive organ screening will be in place in all council hospitals.
The current pilot of HPV vaccine will be considered for scale up.

Diagnosis and referral will be improved in hospitals, especially in regional referral hospitals.
There is also need to attend to palliative care for cancer patients. The sector will advocate
for increased resource allocation, increased joint action, multi-sectoral collaboration and
cancer control partnerships with relevant stakeholders. The MOHSW will promote cancer
clinical and epidemiological research.

5.4.5.3 Oral Health

In collaboration with private partners and NGOs, Council health services will provide
appropriate health promotion and education activities for school children and for
communities through outreach programmes. They will contribute to early diagnosis of HIV
infection and the onset of AIDS, and treatment of oral infections associated with HIV and
AIDS. The MOHSW will advocate for the availability of effective and affordable fluoride
toothpaste.

In addition, the MOHSW will coordinate and facilitate the appropriate and uninterrupted
curative, rehabilitative and corrective quality oral health care services at all levels of service
delivery, in line with the National Essential Health Care intervention Package. This includes
availability of emergency oral health care services in primary health care facilities.

5.4.5.4 Diabetes and Hypertension

Prevention of lifestyle related NCDs, like diabetes and hypertension, increasingly has
become a national priority. More attention will be paid to healthy eating and physical
activities, especially among at-risk communities. School health programmes will incorporate
this in their work. Early detection through regular medical examinations promotion will be
pursued to reduce disability eventualities.

Existing, separate NCD clinics will be integrated into the health care system to enhance
accessibility. Existing facilities for managing chronic communicable diseases such as HIV-AIDS
and TB at the health centre level may be adapted for management of diabetes and
hypertension. The MOHSW will continue to elaborate the National Diabetes Programme in
collaboration with stakeholders. By 2020, all council hospitals will be able to perform
diabetes screening and provide basic treatment.

5.4.5.5 Sickle Cell Diseases (SCD)

The MOHSW will develop a national screening programme for congenital disabilities and for
Sickle Cell Disease (SCD). It will develop genetic counselling and testing for SCD. The health
sector will integrate care for children with asthma and SCD with clinics run for children with
diabetes. It will develop treatment protocols and establish patient support groups.

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5.5 Intersectoral Collaboration for Health

Strategic Direction: The health sector will advocate for intersectoral action and actively
engage in partnerships in addressing the Social Determinants of Health including
implementation of the approach

5.5.1 Water and Sanitation

By 2020, 75% the population will have access to safe drinking water, compared to 52% in
2010 and 90% of the population will have access to minimum sanitary facilities, compared to
60% in 2010. All schools will have adequate sanitary facilities.

The provision of safe water, improved sanitation and adequate hygiene (WASH) is key
towards prevention of the majority of communicable diseases, which are prevalent in the
country, e.g., cholera, typhoid, dysentery, diarrhoea, soil transmitted helminths and
schistosomiasis.

The health sector will advocate for the enforcement of the Public Health Act, 2009 and by-
laws on sanitation and hygiene. Capacity building of communities and Regional and Local
Government Authorities will take place. Promotion materials will become available for
community programmes and community-based events will be organised.

Under the HSSP IV, the WASH interventions will be effectively implemented within the
sector to ensure the country attains Open Defecation Free status by 2020. The interventions
will be twofold: through provision of hygiene education targeting the household level
(reached through CHW and local media channels) and through rehabilitation or construction
of sanitation facilities in public facilities, transport hubs and highway’s bus stops. The
MOHSW in collaboration with PMO-RALG and LGAs will ensure health care facilities are
provided with adequate sanitation and hygiene services both in rural as well as urban areas.
Also waste collection, especially proper disposal of medical waste, is an area of attention for
the health and social welfare sector.

5.5.2 Occupational health

Workplace health programmes focus on occupational safety and health. The Ministry will
advise on safety measures to prevent injuries and diseases and will perform workplace
inspections to enforce legislation. The MOHSW will prioritise high-risk industries, where
exposure to hazardous situations and substances is high, e.g., the mining industry.

Prevention and control of workplace HIV, TB and Hepatitis B Virus will be initiated to prevent
transmission of communicable diseases. Healthy lifestyles will be promoted, including
enhancing the growing interest to invest in sports among employers. Periodic health
screening shall be encouraged to pick occupational health related problems early enough for
definitive intervention.

5.5.3 General and Health Care Waste Management

By 2020, 80% of health facilities will meet the standards for safe health care waste
management. The management of health care waste is an integral part of a national health
care system. The MOHSW is developing guidelines to assist LGAs, Health care facilities and
other implementers on proper management of health care waste. Health facilities will
segregate waste at the point of generation, in order to store, label, treat, transport and

49
dispose of all waste in the manner prescribed in the policy and other laws and regulations.
These interventions will ensure the safety of health care workers, patients, community and
the environment. Other waste management interventions outside of health facilities will be
organised by Local Governments to meet legal requirements for optimal sanitary standards.
To this end, close collaboration with the National Environmental Management Council will
be encouraged.

5.5.4 Port Health services

The health sector will continue to take practical measures to protect the health and
wellbeing of citizens and residents against the international spread of diseases and other
threats by executing International Health Regulations, 2005, through strengthening national
IHR focal point, provision of public health measures and strengthening surveillance systems
to public health risks at points of entry. It will expand port health services and ensure that by
2020 at least 50% of the 20 major points of entry have core capacity developed and are able
to provide access to appropriate medical services, including diagnostic facilities to allow
prompt assessment and care of ill travellers. Close collaboration with the Emergency
Preparedness and Response unit in the Ministry that links up with the Prime Minister’s
Office will be of essence.

5.5.5 Road Safety

The health sector will have to cope with increasing traffic in the country. All Councils and
Regions will have effective systems in place for treatment and referral of injuries and road
traffic accidents. Effective orthopaedic treatment in RRHs will reduce the need for further
referral. They will improve their emergency response and trauma care. Specialised centres
provide support rehabilitation and care of road injury victims and will provide advice,
support and legal redress for victims and their families.

Through PPPs the sector will promote the continuation of intersectoral initiatives on
prevention of road traffic injuries and other injuries. The Health Sector will also advocate for
improvement and enforcement of Road Safety legislation (such as speeding, drinking and
driving, use of safety belts and children’s seats, helmets, timely maintenance of
infrastructure, civil education for road users).

5.6 Emergency Preparedness and Response

Strategic Direction: The MOHSW (in collaboration with other MDAs) will put systems and
structures in place to be able to respond immediately to health related epidemics and crises,
using modern means of communication to ensure global health security.

Recently, health disasters in Africa and on other continents have underlined the necessity to
remain alert on potential crises and intervene immediately when they occur. The MOHSW
will update the multi-sectoral Plan for Emergency Preparedness and Response (EPR),
covering health related emergencies, epidemics and events with a public health impact.
Tanzania will establish a permanent coordinating body which will oversee all Disaster Risk
Management and Health Risks Management activities in line with the International Health
Regulations (IHR) 2005. The MOHSW will produce and monitor an IHR annual action plan,
operationalized through Technical Committees at Regional and Council levels, under RHMTs
and CHMTs respectively.

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Early Warning Institutions (EWI) will inform relevant Ministries regularly, which will take
necessary actions for updating and implementing Emergency Plans. The ministry will
activate an Emergency Operational Centre when needed for daily monitoring, reporting, and
feedback. It will share the reports with stakeholders and will implement corrective
measures, including post-disaster support.

The Health Sector will roll out the electronic Integrated Disease Surveillance and Response
(IDSR) system, for immediate action at all levels. Case detection, notification and
investigation will be done according to international standards. The sector will set up a
mechanism for emergency medical services at all levels including guidelines and protocols
for specific situations.

Emerging and re-emerging zoonoses may cause new epidemics that need to be analysed
through molecular technologies. Veterinary experts and molecular biologists will be
consulted by the health system. There will be comprehensive training in the different areas
of medical care and disaster relief, including the community level. All emergencies will be
documented and evaluated and experiences and lessons will be documented to inform
future interventions.

The MOHSW will set-up and manage Call Centre(s) for the public to contact the authorities.
The MOHSW will conduct awareness campaigns using modern means of communication,
but also local community mobilisers. The MOHSW will develop strategies for psychosocial
support to victims of emergencies.

5.7 Social Welfare service delivery

Strategic Direction: Social welfare will be further decentralised and become a fully–fledged
department in the LGAs. Health channels will be used to reach communities and vulnerable
groups for sensitisation and referral to organisations providing social welfare support.

5.7.1 General

Social welfare services are decentralised to LGAs (operating in villages, neighbourhoods and
wards), which provide a response to the increased social welfare issues in the community,
including catering for Family and Child rights, MVCs, the elderly and people with disabilities.
Councils will be responsible for social welfare and social protection interventions for most
vulnerable groups. In order to harmonise integration of social welfare and health services,
the CHMTs and RHMTs will have social welfare specialists in their teams, to jointly plan and
implement activities.

Gradually, social welfare services will be further devolved and institutionalised in public
health facilities by 2020. Professionals will perform risk assessments that are linked to a
referral system involving a range of sectors and services to determine and respond to the
immediate and long-term protection needs of children and vulnerable groups. Health
facilities increasingly play a role in the system of Birth Registration because the majority of
children are born in health facilities and nearly all children are vaccinated.

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5.7.2 Policies and Strategies

The government will soon endorse the Social Welfare Policy document and Social Work
Council. The National Costed Plan of Action for the Most Vulnerable Children (MCV) II (2013
–2017) will be operationalised to provide child protection services and services to children
out of family care, children with disabilities, and children in conflict with the law. MOHSW
will develop national policies and implementation of community based prevention and
reintegration services for children in conflict with the law, in accordance with the UN
Convention on the Rights of the Child.

The Cabinet Paper and Elderly Act will be finalised in 2015 and guidelines on instituting
social protection and services to person with disabilities, MVCs and elderly persons will be in
place by June 2016. The National Guideline for early identification and interventions for
children with disabilities in Tanzania will be finalised by 2016. Guidelines for care, support
and protection of victims of human trafficking will be prepared.

The MOHSW will establish a comprehensive data base system for Social Welfare services
namely Social Welfare Management Information System by June 2016. This information
system will incorporate the Child Protection Management Information System presently
under development. A Monitoring and Evaluation framework on social welfare services will
be operational by June 2016.

5.7.3 Vulnerable groups

5.7.3.1 Services to People with Disabilities

The MOHSW in collaboration with non-governmental partners will strengthen Community-

Based Rehabilitation (CBR), support and protection services for persons with disabilities. The
identification of persons in need and the care for these groups in the communities will
improve through the LGAs. The MOHSW in collaboration with PMO-RALG will raise
awareness on CBR, develop guidelines and provide training to LGAs.

Children with disabilities will get access to fundamental services through the communities,
for example health care, education, rehabilitation services and assistance in referral to
institution-based rehabilitation. The government will renovate Vocational Rehabilitation
Training Centres and ensure that human resources, equipment and training materials are in
place. Experts in rehabilitation shall be integrated at all levels of care.

5.7.3.2 Family, Child Welfare and Early Childhood Development

The government will strengthen multi-disciplinary, evidence-based prevention and response

services for children who are victims of violence (including genital mutilation), abuse,
neglect, exploitation and trafficking through scaling up of a children’s protection system in
the LGAs. This will involve the development of community services to support and
strengthen families and to prevent separation of children from the family, effective systems
of referral of children suffering or at risk, and the development of alternative family services,
including kinship care, fostering, fit person and adoption services as well as services for
children leaving the care of the local government authority. In addition, the Government will
enhance the existing monitoring and inspection system for children’s residential homes,
setting and maintaining quality standards. The government will roll out regulations,
guidelines and other relevant tools and sensitise, train and equip frontline workers and
LGAs.

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The Social Welfare sector will strengthen the economic capacity of the Most Vulnerable
Children (MVC) households and parenting skills to facilitate the provision of adequate care
and support services to identified children. The sector will advocate for the review of the
legal framework and development of programmes to strengthen family stability. This will
require, but not limited to, review of the Marriage Act, sensitisation and information on
family welfare and matrimonial issues. Conflict resolution and mediation for marriage
practitioners will be stimulated.

5.7.3.3 Services for the Older People

The government will anticipate changing cultural patterns with regard to care for older
people. The government will enact the Older Persons Act, and engage in better care for
elderly in homes. It will stimulate PPP to establish homes, and at the same time improve
quality control on homes. Geriatric care will improve especially when there will be more
attention for non-communicable diseases and cancer treatment. National, zonal and
regional hospitals will develop expertise and disseminate this to lower level hospitals.

5.7.4 Juvenile Justice

5.7.4.1 Corrective Treatment

The MOHSW will scale up community-based Prevention and Reintegration Programmes in

order to prevent juvenile offenses and to promote alternative measures to judicial
proceedings against children and the detention of children in conflict with the law and
children at risk of offending. Likewise the MOHSW will provide services to children detained
in various retention homes. In addition, the Government will renovate retention homes and
approved schools to ensure that human resources, equipment, and training materials are in
place.

5.7.4.2 Rehabilitative Youth Services

The Department of Social Welfare will create a Juvenile Justice Specialisation to ensure the
rights of children in conflict and in contact with the Law are upheld. Social welfare officers
will be trained in the subject. The sector will raise public awareness and engagement in
protection of the rights of children living and working in the streets. It will re-unify children
with their families and initiate retention mechanisms.

5.7.5 Accountability mechanisms for child protection

The Department of Social Welfare already provides supervision and guidance to local
government authorities on child protection and provides for a case management system.
The government intends to strengthen the role of the department to include the setting of
performance targets, quality standards and data collection as well as a research and analysis
management programme.

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6 Health Care Support Systems
6.1 Human Resources for Health and Social Welfare

Strategic Direction: Adequate staffing of health facilities and social welfare institutions at all
levels is the most critical success factor in achieving quality health and social welfare
services. Equitable staff distribution, retention and maintaining high performance standards
for employed professionals will be at the heart of quality improvement in health and social
welfare services. Human Resources production will follow HSSP IV priorities.

By the end of the HSSP IV period, 90% of the public primary health facilities in Tanzania will
have qualified staff according to minimum norms, while there is a sufficient number in the
country for private providers to employ staff according to accreditation standards. In at least
150 public health facilities in selected regions, the private sector will contribute to HRH
through PPP arrangements.

6.1.1 HRHSW planning and management

The development of Human Resources for Health and Social Welfare (HRHSW) continues to
be a main health sector priority in the HSSP IV. This is also reflected in the BRN work streams
that emphasises the effective distribution and performance of health staff. The MOHSW will
strengthen leadership and management capacities of HRH officers for adequate planning at
all levels and will enhance inter-ministerial coordination.

The Directorate of Human Resources Development will plan, regulate and monitor HRHSW
activities in Tanzania, with a focus on equitable distribution of staff over the country in the
context of the BRN strategies. The MOHSW will be increasingly responsive to HRHSW needs,
based on developments in the health sector, e.g., with upcoming use of ICT in health. It will
improve its recruitment policies. The MOHSW will revise staffing norms, replacing fixed
staffing in institutions with evidence-based staffing norms, taking into account workload,
burden of disease, trends in staffing and attrition. The MOHSW will reconsider professional
profiles and propose adjustment of legislation and regulations if needed, e.g., to enable task
shifting of medical and other related professionals, as well as formalise current untrained
Ward Attendants to skilled Health Attendants, by taking them through competency-based
training.

LGAs will be capacitated to plan their local human resources needs based on the revised
staffing norms for health facilities and institutions and to manage human resources
adequately, including induction and coaching of new staff. The MOHSW will develop criteria
for bonding and rural placements to stimulate equitable distribution of staff; the PMO-RALG
and LGAs will enforce compliance.

6.1.2 Distribution of staff

One of the BRN priorities is a balanced distribution of health professionals over the country
and simplification of administrative processes to enable such distribution within the Regions
between Councils and within Councils. Distribution of skilled HRHSW will be strategically
aligned with priority service delivery areas (e.g., a sufficient number of skilled health workers

54
in facilities that have been strategically selected for EmONC) and prioritise underserved
areas in line with BRN plans. The Staffing Levels 2014 – 2019 (establishment) will guide the
distribution process. The MOHSW will also improve distribution of specialised cadres, e.g.,
with mental health training, so that their capacities are optimally utilised.

The health sector will improve systems of recruitment, career development and retention of
HRHSW. Better information on available posts, active recruitment and provision of
incentives will assist in moving personnel to areas most in need. The system of allocation of
recruitment permits and personal emoluments (PO-PSM) and of deployment and incentives
(MOHSW-DAP and DHR) will be synchronized to ensure proper matching of the appropriate
numbers and skills of HRH needed by the councils. LGAs will be stimulated to use incentives
for retention of health care workers. Two year compulsory attachments for recently
graduated clinicians and nurses will be introduced and strictly implemented. By 2020, over
90% of these critical cadres will take part in the attachments.

Private providers will be engaged in providing professional health services in public facilities
through innovative PPP contractual arrangements in at least 25% of identified Councils.

6.1.3 Performance management

By 2020, performance management systems will be in place in all health facilities, both
collective (Star Rating) and individual (OPRAS).

During the HSSP IV implementation period, operationalising the HR Performance

Management System is a priority as it is reflected in the BRN interventions. The MOHSW will
develop minimum performance standards in line with service delivery requirements on
which the performance assessments will be based. Performance Management will take
place at facility level (certification or accreditation) and at individual level (OPRAS and
Results-Based Financing). There will be a mix of monetary and non-monetary incentives for
high performers.

Human Resource managers at all levels need to be trained in this new approach towards HR
management. It will require introduction of effective, internal, supportive supervision and
coaching to ensure that health and social welfare professionals perform to the best of their
abilities.

6.1.4 Information and research

The health sector will improve coverage and quality of HRHSW information systems and
strengthen the inter-operability of different systems (including HRHIS,TIIS, HMIS, EPICOR and
LOWSON systems). HRH operational research will take place to measure the effects of
policies with regard to performance management, productivity and retention. This research
will inform policy decisions.

6.1.5 HRHSW development

The health sector will further develop and maintain high quality HRHSW production, to meet
the demands of the health sector. The number of qualified health staff will increase to over
150,000 in 2020. The MOHSW will support Health and Social Welfare Training Institutions to
achieve this.

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The emphasis will be on increased production of middle level cadres (AMO, CO, nurses,
midwives, SWOs) as per HRHSW production plan. The HRH production plan will be revised
according to agreed staffing norms and in the HSSP IV. The production of pharmaceutical
and laboratory staff will increase to cover the needs of the sector. There will b e better
coordination of training activities to meet standards of quality and quantity of numbers to
be trained in pre-service training. Collaboration with NACTE will be improved. The health
sector will engage in public-private partnerships for increasing training of health staff. By
2020, there will be a balance between the need for new cadres in the health sector and
production of new graduates for critical professions, based on joint planning between
training institutions, MOHSW, PO-PSM and PMO-RALG.

As part of the new Community-Based Health Strategy 2015, Community Health Workers
(CHW) will be formalised and standardised. The role of CHW cadre for curative services
(iCCM/IMCI and others) and health promotion shall be clearly defined in line with the task
sharing policy guidelines and implementation plan. The curriculum for this one-year training
course is being developed and accreditation by NACTE will be obtained. At the same time,
other shorter training programmes for CHWs have to be phased out or integrated as
modules in this CHW training. A clear plan for transitioning from existing CHW schemes
involving health volunteers to a professional CHW cadre linked in the local health system will
be developed. The HRH production plan will be revised to project CHW output numbers per
year and distribution over the country, and a financing plan will be developed.

The health sector will enhance the quality and effectiveness of Continuing Professional
Development (CPD) Programmes and reduce fragmentation. Academic institutions and
Professional Associations will participate in CPD, offering accredited modules, which can also
be used in upgrading of staff through coordination with Professional Councils. Institutions
will make use of modern teaching methods, e.g., distance-learning using ICT, etc. Efficiency
gains will be achieved by coordination and streamlining all CPD activities in the country. The
MOHSW will regulate in-service training. By 2020 all CPD activities (also provided by Disease
Control Programmes and NGOs) will require accreditation.

The MOHSW has established eight Zonal Health Resource Centres (ZHRCs) in order to
support health care delivery. The zones cover two to six regions and provide linkages
between national, regional and Council levels. Their roles include development of human
resources for health (RHMT, CHMTs and health facility capacity building support and
participation in Star Rating), conducting research and dissemination of health information.
In order for ZHRC to effectively perform their roles, their position will be reflected in the
MOHSW organisational structure, the linkage to national, regional and Councils level be
clearly stipulated.

6.1.6 Nursing and Midwifery Services

The nurses and midwifes, individually and collectively, as the biggest professional group in
health care, carry a strong obligation to provide quality services. Thus, in the current HSSP
IV, nursing and midwifery services will focus on increasing skills for nurses and midwives
which will contribute to the government commitment in reaching public expectations by
providing quality services. Nursing Services will contribute to QI efforts (described in section
5.2). The Tanzania Nurses and Midwives Council will champion ethics for clinical practice to
safeguard patients’ rights (as described below).

During the HSSP IV period, the nursing and midwifery services will concentrate on creation
of a clinical instructors’ programme for students and interns, in collaboration with the

56
nursing schools. This program will facilitate learning and adaptation of skills. The MOHSW in
collaboration with CHMTs will introduce an orientation plan to newly and relocated staff and
employees. This will facilitate the understanding of the new working environment. The
MOHSW will facilitate exchange of experiences of initiatives done by community nurses and
midwives in the provision of care particularly at the family level.

6.1.7 Professional Regulatory Councils

Professional regulatory bodies in the Health Sector are either Councils or Boards. The
Councils include the Medical Council of Tanganyika, the Tanzania Nurses and Midwives
Council, the Pharmaceutical Council, the Health Laboratory Practitioners Council, the
Medical Radiology and Imaging Professionals Council, the Optometry Council, the
Environmental Health Practitioners Registration Council) and the Traditional and Alternative
Health Practice Council. On the other side the Boards are the Private Health Laboratory
Board and the Private Hospitals Advisory Board. These bodies will contribute to CPD
coordination and accreditation. They will accredit CPD providers and courses and provide
technical assistance in preparation and implementation of CPD activities. By 2020 all CPD
activities in the health sector will be subject to accreditation. Gradually, a system of re-
registration for health professionals will be introduced, as part of the quality assurance
system.

The professional regulatory bodies will enhance compliance to professional ethics. They will
update existing documents on medical and professional ethics and share those with
professionals. Through decentralised structures, they will monitor compliance and perform
regular studies and evaluations. Promotion of gender and rights-based approaches in health
is an area of work for organisations that will involve advocacy among leaders and decision
makers to promote the institutionalisation of gender and human rights concepts and
methods (tools) in schools, colleges and other training institutions (see Section 7.3 for
further detail on gender and UN publications (UNICEF, WHO) on applications of rights-based
approach in health).

Professional associations have an important role in promoting professional standards,

commitment, attitudes and ethics e.g., during annual scientific conferences. There is no
structured mechanism to present their inputs in policy forums. The Federation of Tanzania
Health Professionals’ Associations will be formalised to be the voice of health professionals
in policy and decision-making bodies in the health sector. Professional associations will be
capacitated to organise and conduct regular CPD activities in line with national CPD
guidelines approved by the statutory regulatory bodies.

6.2 Essential Medicines and Health Products

Strategic Direction: Essential medicines and health products will be quality assured, rightly
priced, efficiently delivered through MSD, and complemented by decentralised procurement,
engaging with the private sector. National stewardship and regulatory oversight will be
coupled with custodianship from local government and mechanisms for public accountability.
The appropriate use of medicines will improve through quality assurance,

During the HSSP IV period, well-coordinated, responsive and reliable procurement and
distribution systems, incorporating private sector participation, will be in place at the
national level, fulfilling demand for quality assured medicines and health commodities. By
the end of the HSSP IV period, stock-outs of essential medicines for the main health

57
interventions and most common (top 10) conditions in health facilities will happen only
incidentally.

6.2.1 Stewardship from the national level

The MOHSW will expedite the structural changes and organisational development for
improved governance, ownership and accountability in the supply chain, in line with the BRN
commodities work stream recommendations and the National Pharmaceutical Action Plan
2014-2020 (NPAP 2020). The MOHSW will put in place appropriate systems for planning,
quantification and co-ordination of procurement, storage and delivery of donated
consignments of health care commodities as well as those for vertical programmes.

Enhanced regulatory capacity and resources of the Tanzanian Food and Drug Authority
(TFDA) and Pharmacy Council will manage market control of medicines, diagnostics and
medical devices, and oversee professional conduct in the practice of pharmacy, in the
interest of public safety. Existing mechanisms at TFDA for pharmacovigilance will be
reinforced, including the process for providing feedback to the source of the report on
adverse drug reactions and quality problems.

The MOHSW will review the regulatory and oversight strategies for the pharmacy profession
and for distribution outlets (ADDOs), and through the Pharmaceutical Council will develop
and enforce codes of conduct and guidelines for the management of inspections at all levels.
The MOHSW will encourage the ADDOs to engage in greater self-regulation and build their
own capacity so that there is greater access to approved medical products, especially in rural
areas.

6.2.2 Planning, Quantification, Costing, Procurement and Monitoring Supply

Chain

The tendering and procurement processes at MSD will be improved to ensure timely
availability of good quality and affordable medicines as well as enough safety stock at all
levels at all times. The product range at MSD will be rationalised on the basis of the clinical
importance of an item, as well as the products annual turnover and frequency of demand.
MSD’s capacity in the forecasting of demand and stock control will be improved.

Accurate information needed for the management and monitoring of the health commodity
supply chain will be available to ensure that adequate quantities of the right health
commodities are consistently available at the point of service to meet patient needs. The
MOHSW will roll out the e-LMIS to councils, hospitals, and primary health care facilities,
where appropriate infrastructure exists. The information systems will support increased data
visibility, data quality, and access to information, improving health commodity related
decision-making. The MOHSW places information in the public domain regarding the
resources provided to, and used by health facilities, in line with the Open Government
Partnership.

The MOHSW and PMORALG will quarterly appraise the supply chain, perform benchmarking,
and adjust management strategies that aim to improve the use of data for decision-making
for key supply chain decisions at various levels.

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6.2.3 Facility Planning, Quantification, Costing, Procurement and Utilisation of
Medicines and Health Products

Evidence-informed selection and rational use of medicines and health technologies will take
place in public and private sector health facilities and the community, based on a list of
standardised health technologies, with effective mechanisms for continuous maintenance.

CHMTs will establish technical committees or task teams to oversee commodity

management systems, procedures and performance, as well as the rational use of medicines
and laboratory supplies across all council facilities. Health facilities will have Medicines and
Therapeutics Committees. RHMTs and CHMTs will promote best practices in medicines and
supplies management and effective and well-targeted supportive supervision using the
toolkit for medicines management and governance.

CHSBs and HFGCs will perform their functions to oversee and supervise commodities
management, performance monitoring mechanisms, incentives and rewards. Civil Society
Organisations (CSOs) will be involved in supporting local accountability and governance
structures. Public accountability will reduce pilferage and misuse of medicines and supplies.

MSD zones and Councils will agree on service agreements that specify the roles and
responsibilities of both parties. Appropriate models for procurement at the local level will be
identified, evaluated, and adopted (e.g., pooled procurement, prequalified suppliers,
redistribution, etc.). Adequate systems of distribution to end-users (e.g., involving the
private sector) will be put in place.

There will be medicines information, education and communication strategies for health
workers and communities through medicines and poison information centres at zonal and
regional ‘hubs’.

6.2.4 Research and Production

The MOHSW will promote investing in domestic pharmaceutical production through the
implementation of the Tanzania Pharmaceutical Manufacturing Plan of Action (TPMPA 2014
-2018) so that they can be able to meet 60% of the national medicine need by the year 2018.
MOHSW, COSTECH and academic institutions will create an enabling environment that will
maximise the research and development capacity of local pharmaceutical industries. The
MOHSW will facilitate Public Private Partnerships in local production of ‘right-priced’ quality
pharmaceutical products, while ensuring sufficient competition through importation. TFDA
will also encourage more qualified suppliers and manufacturers to enter the market in
Tanzania for the purpose of sourcing additional quality medical products at reduced prices.

There will be a regional databank of African traditional medicines, medicinal plants in order
to ensure their protection in accordance with regimes and related intellectual property
rights governing genetic resources, plant varieties and biotechnology.

6.2.5 Financing Medicines, Commodities, Devices and Supplies

The MOHSW will develop a medium term financial plan for medicines, health technologies
and supply chain operations that is harmonised and aligned with HSSP, and effectively
implemented and monitored. Price regulations will be introduced to address affordability of
pharmaceuticals in both public and private sectors. Under the HFS, the country will develop

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regulatory mechanisms for fair pricing and avoidance of monopolistic behaviour.

The MOHSW, in collaboration with PMO-RALG, will formulate transparent and efficient
procedures for access to funds that are generated by health facilities through various means
including insurance, cost-sharing or results based financing in order to replenish medicines
at those facilities and avoid out of stocks.

By 2018, the Government debt to MSD will be cleared. This will enable timely and adequate
disbursement of funds for international procurement of commodities and supplies. MSD’s
operational and service charges will be based on the results of an independent analysis of
MSD’s current and projected operational costs. The service charges will ensure that MSD
grows its capital to match the increase in demand from expanding health services and cater
for integration of vertical programmes’ medicines and health products into MSD operations.

6.3 Infrastructure, Transport and Equipment

Strategic Direction: The health and social welfare sector will engage in balanced and
sustainable infrastructure development with emphasis on geographic prioritisation, quality
and maintenance, to provide equitable access to quality services for the population. The LGAs
will link infrastructure development to HRHSW planning and equipping of health facilities.
Newly constructed and refurbished facilities will meet standards for future accreditation.

In the HSSP IV period, the health and social welfare sector will construct nearly 800
dispensaries, 35 health centres, 9 district hospitals and 4 regional hospitals, as well as social
welfare institutions. Around 5,800 health facilities (around 70% of all facilities) will undergo
maintenance works. Maintenance and replacement of equipment will be incorporated into
the Star Rating improvement programme, reaching 80% of facilities.

6.3.1 Infrastructure

In the HSSP IV period, the number of health centres and dispensaries in rural areas will
increase to improve geographic accessibility in most under-served areas. Existing
information systems will be used to disclose those areas of high need, and Councils will plan
for construction. PMO-RALG and funding agencies will allocate adequate funds and disburse
timely as per approved budgets for rehabilitation and construction of health facilities.
Around 600 new facilities will be constructed in the five year period.

The MOHSW will review the health facilities standard infrastructure guidelines to guide LGAs
in more balanced infrastructure development, ensuring that facilities are constructed and
rehabilitated to meet accreditation standards. Both newly constructed and refurbished
facilities will ensure adequate space for storage of pharmaceuticals and medical products,
private treatment rooms for patients and for delivery of pregnant women. Disability
friendliness shall be adhered to in the design and subsequent construction of infrastructure.

PMO-RALG and MOHSW will introduce a monitoring system of health facilities and actual
status to have better overview of specific needs and constraints and anticipate renovations
and replacement of equipment (as part of the Star Rating activities).

As part of the BRN programme 2015 – 2018, health facilities in selected regions will be
refurbished, upgraded, electrified and furnished with a safe water supply, in order to
provide BEmONC or CEmONC services. This programme will also improve other services

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through a focus on quality improvement. LGAs, CHMTs and RHMTs will ensure that
completed facilities are fully equipped and adequately staffed before construction of new
ones begins. At the same time, these government entities will look for equitable distribution
of facilities to reach populations in underserved areas, and will avoid duplication where
private health facilities exist.

6.3.2 Maintenance of equipment

Maintenance of equipment will be further decentralised to LGAs, who will employ new
cadres of biomedical engineers and will equip basic maintenance workshops.

The MOHSW will produce guidelines for LGAs/CHMTs to introduce a system of preventive
maintenance. The MOHSW in collaboration with MSD will produce lists of standardised
equipment and will negotiate with international agencies to adhere to guidelines for
standardised equipment, in order to plan, procure and stock spare parts efficiently.

6.3.3 Transport and Ambulance Services

CEmONC under the BRN programme requires a functional referral system, with operational
ambulances. The MOHSW will coordinate the setting up of a mechanism for emergency
medical services at all levels, including guidelines and protocols. The MOHSW will also
investigate options to establish a toll free telephone number 115, for emergency calls.

The CHMTs will develop fleet management plans that include preventive maintenance of
vehicles and schedules for replacements of means of transport for both health and social
welfare services. This will be included in CCHPs. The MOHSW will implement a monitoring
system to follow up on service readiness of means of transport.

The Government aims at reduction of donor dependency for the provision of vehicles and
will produce an investment plan. The MOHSW will investigate possibilities for engaging the
private sector in transport services for health. It will advocate for streamlining a mechanism
for ambulance specification, registration and management.

6.4 Monitoring and Evaluation Systems in Health and Social Welfare Sector

Strategic Direction: M&E Systems will be focusing on data-for-decision making, utilising web-
based data collection and analysis, linking information systems, providing stakeholders with
access to data. Under the BRN, there will be quarterly feedback on performance to service
providers and managers for immediate action.

By 2020, over 95% of health institutions will provide timely and complete data of services
and systems using automated data transfer systems. 100% of the KRA indicators will be
monitored quarterly, and actions will be undertaken based on analysis.

The MOHSW will provide publicly accessible information on the HSSP IV indicators listed in
annexes 3, 4 and 5 according to the time frames mentioned in the indicator list.

The country has a functional organisation of routine health management information system
(HMIS), specific information systems, sentinel surveillance, surveys, census and specific
research, to provide information on the health status and the performance of the health

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sector. Improvement of data quality and exchange between data systems will be one of the
focuses of HSSP IV.

6.4.1 HMIS

The health sector will achieve improved efficiency of the Health Management Information
Systems (HMIS) and its associated processes to meet health sector Monitoring and
Evaluation (M&E) requirements. The MOHSW will reduce the burden of HMIS on health
workers by prioritising data elements and expanding the use of electronic tools. Electronic
registers for service provision and electronic medical records will enable automated
aggregate reporting incrementally. In addition, the age-disaggregation of routine reporting
will be improved so that decision makers and implementers better understand the coverage
of various health services by different segments of the population (e.g., children,
adolescents, youth) and address gaps through health promotion and other strategies.
Capture of referral, zonal and national hospital data will improve resulting in more complete
information.

HMIS data quality will improve by strengthening accuracy, completeness, and timeliness of
data. MOHSW will work with partners to agree on data quality attributes and data quality
check instruments for consistent use. Data quality checks will be integrated into routine
supportive supervision, routine monitoring of data accuracy indicators including validation
and outliers, automated interpolation for missing data. The DHIS-2 web-based software will
allow for real time data control and feedback to facilities. The BRN quarterly progress
assessment will provide immediate feedback on data quality.

MOHSW will coordinate the approach to facility assessments across ministries, directorates
and disease control programmes to increase efficiency of operations. There will be a
coordinated approach for the health sector that addresses all facility assessment
requirements and merges different methods, for example Service Availability and Readiness
Assessment, Service Provision Assessment, BRN Star Rating, disease programmes balanced
scoring cards, etc.

6.4.2 Other Data Systems

The health and social welfare sector will improve and integrate systems including data
collection tools, planning, budgeting and reporting tools across government (Council Health
Profile, Health Facility Profile, DHIS, HRHIS, e-LMIS, Lower Level Facility Planning Templates
Comprehensive Hospital Operational Planning template, CCHP planning Templates and
PlanRep and Epicor database systems, as well as specific disease control planning and
reporting systems). The technical integration will be discussed under section 6.5 ICT. The
MOHSW will develop an indicator registry, which can be accessed by all systems. The
MOHSW will work with PMO-RALG and partners to develop a Geographic Administration
Registry.

The health and social welfare sector will continue to use surveys and sample-based sentinel
sites to provide nationally representative evidence on community health status and vital
statistics. Collaboration with the Agency responsible for births and deaths registration shall
be important to determine the readiness of this source for generating vital registration data.
A coordinated approach for sustaining and increasing the use of survey data and SAVVY will
be introduced. This will enable more in-depth analysis and identification of regional
priorities and constraints.

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The sector will improve data collection and analysis with regard to nutrition, linking
information on food security to data concerning malnutrition. This will enable identification
of weak spots and vulnerable areas.

6.4.3 Operational Research and Surveys

Research in health and social welfare is increasing in Tanzania, in eight medical universities
in the country and in research institutes like National Institute for Medical Research (NIMR)
and Ifakara Health Institute (IHI). The country has identified and documented the national
health research priorities. The MOHSW will stimulate more joint research together with
academic institutions that fits within these priorities, to be relevant for the country. It will
share the research priorities with international agencies.

More research will be shared with policy makers and practitioners. The MOHSW will
advocate an open access policy to share research outcomes on the internet and make
information available for interested parties. The MOHSW will activate the National Health
Research Forum, to become a platform for exchange of knowledge.

6.4.4 Use of Data and Knowledge Management

Increasingly, information coming from the health and social welfare sector will be used for
priority setting, e.g., distribution of personnel or procurement of medicines. Analysis,
synthesis, and dissemination of information will improve through automated systems, and
made accessible for many stakeholders. This will facilitate data use and accountability for
evidence-informed decision making. The quarterly assessment of progress in KRAs will be
enabled through timely and correct provision of information on selected indicators.
Information will be available for annual planning at Council and regional level. Indicators,
which are in use at all levels, will be available online for direct use.

The MOHSW will contribute to legal frameworks for protecting individual patient data and
will guide the sharing of aggregated data in order to guarantee privacy Information will be
used for planning and management decision making. Indicators are in use at all levels and
will be monitored regularly. The MOHSW will build capacity in translating scientific results
into policy briefs and encourage dialogue with policy makers. The recently developed Data
Dissemination and Use Strategy will provide guidance toward implementation.

The MOHSW will revitalise and strengthening its library and electronic archiving of key
documents and will encourage Hospitals and RHMTs, CHMTs to manage electronic libraries
for ease of retrieval and future use of guiding documents. The Ministry will provide courses
and certifications for M&E, and will develop consistent training for all cadres, and common
definitions of key terminology.

6.5 Information and Communication Technology and e-Health

Strategic Direction: The health and social welfare sector will embrace the rapid development
of ICT for improving administrative processes, patient/client recording and communication.
The MOHSW will stimulate the development and guide interoperability of systems.

By 2020, all hospitals in the country will make use of ICT applications for administrative and
medical processes. At least 25% of the primary health care facilities will also use ICT utilities,
starting in urban areas.

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In the HSSP IV period, major developments are expected around Information and
Communication Technology (ICT), including web-based and mobile data transmission. The
previous sections refer to specific computing systems and tools that address the high-
priority needs of the health sector to improve efficiency and effectiveness (e.g. DHIS-2, LMIS,
HRIS, PlanRep).

The e-Health Strategy (2013 – 2018) will be the basis for further development of
infrastructure and applications. ICT will be used to streamline and improve administrative
processes (e.g., in planning and reporting) and will be used for specific medical purposes
(e.g., electronic patient files) or communication with the population, also called TeleHealth
(e.g., websites, SMS text messages). ICT will also be used for teaching, training and
communication with professionals in the health and social welfare sector.

The e-Health Strategy focuses on the use of available resources and solutions to facilitate
the transformation towards ICT uses in the health sector. The National e-Health Steering
Committee of the MOHSW will guide the process, and the MOHSW ICT Unit will serve as
Secretariat. The ICT Unit will provide e-Health standards, rules, and protocols for
information exchange and protection. It will coordinate management of existing and newly
established systems within the health sector to eliminate silos and duplication of efforts.

The first priority in ICT is to enable data exchange between existing systems (mentioned in
the sections above) in order to facilitate data analysis with information from different
sources. Some of the relevant systems are managed by LGAs or PMO-RALG and require close
collaboration between ministries. The linked systems will constitute the National Health
Information System. By 2018, the system will be fully functional.

In ICT, many private providers are actively offering a wide range of applications and software
solutions. This area therefore is very suitable for public private partnerships and for
international collaboration. The MOHSW will guide the quality of private initiatives, the
privacy of personal data, and interoperability of systems.

6.6 Health Financing

Strategic Direction: Cost-effective, quality health services should be available to all residents
without financial barriers at the time of need. The goal of Tanzania’s health financing
strategy is to enable equitable access to affordable and cost-effective, quality health care
and financial protection in case of ill health, according to a nationally defined standard,
minimum benefit package.

Increasingly new mechanisms of resource mobilisation will contribute to financing health

and social welfare services. The Single National Health Insurance (SNHI) will be operational
countrywide in 2020. Levies and special taxes will contribute to closing the resource gap.

6.6.1 Health Financing Strategy 2015-2025

Through a participatory process led by the MOHSW, stakeholders have developed a new
health financing strategy (HFS), which will align with the HSSP IV and continue thereafter as
the country aims to achieve universal health coverage. The HFS shares the vision of HSSP IV
in improving the quality of health services and increasing equitable access. It will harmonise
the fragmented health financing architecture by combining insurance schemes to achieve

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efficiencies in scale and cross-subsidisation (by creating one joint risk and financial pool).
HFS aims to moving towards a more sustainable and efficient architecture for raising
(particularly domestic financing), combining, and deploying overall funding for health, with
defined roles for certain critical institutions.

A primary focus of the HFS will be to make a standard minimum benefit package of primary
and secondary health care services fully accessible to all Tanzanians with a particular focus
on the poor and vulnerable groups, and to ensure that these services are fully funded. As an
essential part of this vision, the country will aim to reduce the dependency on external
funding sources and move towards more sustainable domestic avenues for funding, with a
clearly defined role for the private sector. The following sections describe the key elements
of the proposed HFS and its alignment with HSSP IV goals.

6.6.2 Single National Health Insurance

It is widely accepted that pre-payment mechanisms such as social health insurance help to
increase financial protection against the consequences of ill health. Currently, many
different health insurance schemes operate in Tanzania, e.g., CHF/TIKA, NHIF, NSSF-SHIB,
etc., which have not reached sufficient scale as a proportion of the total population covered.
There is some progress in raising coverage with the existing schemes. The HFS hence
proposes an expansion and consolidation of health insurance around a new mandatory SNHI
programme. All Tanzanian citizens are expected to participate through contribution
payments. The poor and vulnerable will be identified, based on the national socio-economic
targeting mechanism applied by TASAF, and will receive full subsidisation. Additional
resources from government revenues, including new tax levies as necessary, and continuing
external development partner funding sources will be combined (or pooled) into the SNHI.

6.6.3 Minimum Benefit Package

The SNHI will use its combined financial resources to procure the health services that are
agreed as a part of the standard minimum benefit package (MBP). The MBP will be a formal
legal entitlement for the entire population and is discussed next. Appropriate legislation and
the establishment of an appropriate health insurance regulatory system will support the
establishment of the SNHI. The NEHCIP-Tz of 2013 defined those interventions with the
greatest impact on the burden of disease across the levels of the health care system. It
needs further refining based on new insight of priority setting in context of available
resources in the country. Drawing from the core of the NEHCIP-Tz, the MBP is formulated as
the standard minimum package of services that can be sustainably funded within the
available resources pooled for the SNHI. When citizens require MBP services from their
nearest health facility, they can be assured of availability of essential medicines and health
products, and of health care worker time. SNHI will pay health facilities the services to
reinvest in procurement of medicines, health products and other supplies, as well as
maintenance of infrastructure. As more resources are sustainably combined, the HFS allows
for a gradual transition towards a more comprehensive MBP for the entire population.

6.6.4 Financing Public Health Activities

The focus of the MBP procured by the SNHI is on individual level interventions around
preventive and curative services. It is assumed that community-level, health promotion and
certain public health interventions (e.g., environmental health, mass drug administration for
neglected tropical diseases) will remain with the MOHSW and PMO-RALG and will be
financed as per current norms.

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6.6.5 Mobilising Resources for Health and Social Welfare

Currently, about 8% of the GOT budget is allocated to health while only 1% of the health
budget is allocated to social welfare services. External resources play a prominent part, with
large contributions from DPs, through basket funding, programme funding and off-budget
funding. As external resources plateau or decline, other funding sources will have to come
into play, and the government will need to raise its contribution from general revenue to the
health sector budget. These issues are discussed in more detail in Section 8. The principle of
the HFS, which echoes the HSSP IV, is partnership. In this context, the HFS anticipates that
those Tanzanian citizens with the ability to pay will contribute a fair amount to the SNHI, in
addition to general taxation. Resources will also be sought via special levies from certain
economic activities, including those harmful to health, such as alcohol and tobacco sales.
Levies through vehicle insurances could contribute to covering expenses for medical and
rehabilitative services caused by road traffic accidents. General or more specific Trust Funds
or Revolving Funds could be initiated to cover costs, maybe contributing through the SHNI.

Resource mobilisation at community and Council level can be strengthened further, when
communities take increased ownership of health facilities through decentralisation. Local
philanthropy can contribute to health and welfare related activities. Councils can allocate
considerable funds for social welfare as has been shown in examples. Such local resource
mobilisation has not been incorporated in the scenarios, as the size and geographical
distribution is not known.

6.6.6 Allocating resources for the health sector

The suggested purchaser-provider split recommended in the health financing strategy will
facilitate efficient use of resources, particularly for disease treatment. The MOHSW will
devise mechanisms to ensure that technical and allocative efficiency in the allocation and
use of resources is also attained, taking into consideration the geographical, age, sex and
income groups involved. The MOHSW will identify the pattern of health expenditures and
will undertake regular and periodic studies on allocative efficiency to get a full picture of
allocation, disbursements and expenditures.

6.7 Financial Management System

Strategic Direction: The MOHSW and partners in the health sector will develop an action plan
for improvement of Public Financial Management in line with the national reform
programme to enhance transparency and accountability.

The aim of Public Financial Management (PFM) is to guarantee the flow of public funds to
service delivery units, ensure efficient and effective use of resources, attain development
results, while working in a transparent and accountable manner.

Tanzania is in the fourth phase of the PFM Reform Programme (2012/13 – 2016/17). The
programme sets the national agenda for PFM, initially with five Key Result Areas: Revenue
Management; Planning and Budgeting; Budget Execution, Accountability and Transparency;
Budget Control and Oversight; Change Management and Programme Monitoring and
Communications. In 2014/15, a sixth Key Results Area has been added – LGA PFM Reform.

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The MOHSW together with the MOF and PMO-RALG will produce and monitor an action
plan to implement the PFM Reform Programme at all levels of the health sector.

With regard to the action plan the following will be included and implemented in line with
the targets of the National PFM Reform Programme:

Revenue management: Procedures will be formulated for management, reporting and

accountability of all health revenue streams including insurances. Decentralised forms of
resources mobilisation will be accounted for properly, without transferring these funds to
central level (decentralisation of fiscal management);

Planning and budgeting: the sector will transform to activity-based budgeting for the health
and social welfare sector, which will enable results-based budget analysis at all levels
(clarifying the link between investments and results);

Budget Execution, Accountability and Transparency: The sector will aim for improved
procurement and cash management, improved management of assets, and benefitting from
opportunities to improve financial management provided by the move to International
Public Services Accounting Standards’ accrual accounting. Further clarification with regard to
Decentralization-by-Devolution; most of the institutions in the health sector are under PMO-
RALG. The financial responsibilities are further decentralised to the facility level, with
attention for community accountability;

Budget Control and Oversight: Within PMO-RALG and the MOHSW, additional capacity will
be created to analyse reports and financial flows, to link expenditure to performance, and
analyse value for money. The analysis can also highlight gross under-expenditure and delays
in utilisation of project funds. Improved arrangements will be put in place to monitor
financial management, value for money, reporting and accounting by institutions which
receive grants from the MOHSW, e.g., Muhimbili, DDH hospitals, Agencies and Boards.
Strengthen collaboration between internal audit functions on issues relevant to the health
sector.

Change Management and Programme Monitoring and Communications: MOHSW will

institute a committee in collaboration with PMO-RALG and MOF, which guides and monitors
the PFM health action plan, and communicates to relevant authorities on progress.

LGA PFM Reform: Procedures with regard to decision-making and procurement need to be
simplified and follow the value-for-money principles, in order to work efficiently for small
institutions like dispensaries or health centres.

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7 Management of Implementation and Governance
Strategic Direction: In line with the BRN approach, the health sector will strengthen
Leadership, Accountability and Partnership to ensure that all involved parties can make their
contributions to improving the health system.
Governance will be inclusive, i.e., empowering communities, involving partners, being gender
sensitive.

7.1 Governance in the Tanzanian Health and Social Welfare Sector Context

There are different national and sectoral laws and regulations that guide and regulate
governance in the Tanzanian health sector. Some of those are listed in annex 1.
Management of health services will take place within the national legal context, which
stretches far beyond the health sector. In the governance framework, different rules,
responsibilities, relationships and interactions among different actors are determined and
organised. In the previous sections under the general policy framework, MKUKUTA, service
delivery, human resources etc., different governance issues have been addressed. This
section highlights key issues, strategies and mechanisms specific to health governance, that
were not dealt with in the previous sections.

The health sector is a complex sector, with many Ministries, Government Departments, and
Agencies involved, especially with a prominent role of PMO-RALG in implementation. There
are also many private and non-governmental players in the sector. In addition, other
stakeholders from outside the health sector may have a major bearing on health, as
explained in Section 3.3.6.

Last, but not least, citizens and communities have high stakes in the health sector.
Governance seeks to encourage shared actions among sectors and actors beyond health,
public and private and citizens for a common goal. It is in the interest of the people and the
Government that communities take jointly responsibility for their own health and wellbeing.

7.2 Specific Areas for Action on Implementation Management and

Governance
7.2.1 Decentralisation by Devolution

PMO-RALG will strengthen its principal role in coordination and administration of service
delivery at Regional and Council levels. The role of the MOHSW is to provide technical advice
and policy guidance as well as capacity building, and to monitor and coordinate all health
and social welfare actors in order to achieve better health for the nation. In addition, the
MOHSW shall have oversight over national, specialised and zonal Hospitals services. The
government will formalise inter-ministerial consultation among MOHSW, PMO-RALG, MOF
and PO-PSM to enhance efficiency in their operations.

LGAs, through CHMTs as part of PMO-RALG, will be overall responsible for implementation,
supervised and guided by RHMTs under the Regional Administration. To this effect CHMTs
and RHMTs will be strengthened in staffing and in levels of capacity including epidemiology

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competencies. At the local and regional level, strengthening of intersectoral collaboration to
realise health in all policies will be further institutionalised, e.g., by strengthening the human
resource base of the RHMTs.

RRHs will continue to improve governance, by equipping their Hospital Health Services
Boards with a legal mandate, and strengthening the Management Boards. Standardised
management systems will be systematically applied and monitored

Social welfare and social protection will become part of the decentralised sector planning
and management system. MOHSW and partners will build the capacity for integrated
planning based on the Social Welfare Policy. The social welfare set up at LGs will concentrate
on family and child rights, elderly care services, and disability services. Coordination units for
food and nutrition focus on childhood, adult nutrition and dietetics and on production,
manufacturing and trading.

Partners in the health and social welfare and nutrition sub-sectors will strengthen evidence-
informed planning and management in primary health care facilities, Council hospitals and in
the CHMTs. Facilities will produce their own improvement plans (e.g., to achieve desired
Star Ratings). Facilities will manage their own funds using their own bank accounts.

The decentralisation of financial management will go hand in hand with (social)

accountability and performance management. The CHMTs will produce their support
activities based on the needs of communities and health facilities, in line with the proposed
decentralisation.

7.2.2 Social Accountability

Social accountability will go hand in hand with community sensitisation to inform the
population, regarding rights and commitments. The MOHSW will revitalise the Client Charter
showing patients’ rights and disseminating it widely among the population. LGAs will
introduce local community scorecards, which enable feedback to health facilities on
performance. The Star Rating System (initial phase of accreditation) will show to the general
public the level of quality of their facility in a transparent way. Performance management
(individual and facility-based) will enhance a culture of accountability.

The sector will improve social accountability through strengthening the HFGCs, which will
have more gender-balanced representation. HFGCs will have specific responsibilities with
regard to management of the health facilities and will relate to Ward Development
Committees. The health sector will work with community-based organisations, civil society
organizations and other non-governmental organizations in this area. LGAs will strengthen
the CHSBs and give them more controlling responsibilities and formal relations to Council
Social Services Committees. The PMO-RALG will develop further guidance on the roles and
responsibilities of management structures and their interactions.

As part of social accountability, M&E systems will become more transparent and accessible
for stakeholders, both at local levels and at the national level. Tools to facilitate application
of a rights based approach in health shall be disseminated and applied among health
managers and communities.

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7.2.3 Performance Management

Performance management will be a crucial innovation during the HSSP IV period. This will be
at the institutional level through the certification and accreditation system, and introduction
of a complaints handling system and feedback mechanism to health facilities. Results Based
Financing will be instrumental in this. At the personnel level, an individual performance
management system will be applied, based on the national OPRAS. National systems will be
developed for local implementation. LGAs, regions and PMO-RALG will be tasked with
making performance agreements, and in following up during their implementation and in
reporting. Harmonisation of automated reporting systems will be stimulated to enhance
inter-operability and transparency of performance assessments. There will be close
monitoring guided by the MOHSW to ensure transparency and accountability.

7.2.4 Partnership

Partnerships in health and social welfare will help to achieve equitable, accessible and
quality health and social welfare services. The MOHSW, PMO-RALG and other MDAs will put
concrete measures in place to implement the Public Private Partnership Policy.

The MOHSW will realign the PPP policy and guidelines with review of PPP legislation and will
continue to sensitise stakeholders. The MOHSW will institutionalise the responsibilities for
implementation of the PPP Strategy at the national level. The MOHSW will establish and
strengthen functional dialogue structures between public and private sectors (including
traditional medicine and alternative healing) to promote effective, sector-wide PPPs at the
national level. For the regional and council levels, the MOHSW will facilitate and provide
support to PMO-RALG to establish and strengthen these structures. In order to understand
the roles and responsibilities at the local and regional levels, further mapping of
stakeholders will be undertaken.

The MOHSW will work in collaboration with the private sector and other government
agencies to identify innovative approaches to financing PPP projects. The government will
facilitate private organisations willing to invest in rural health service delivery and will offer
service level contracts, based on transparent certification and accreditation criteria. The
government will create a level playing field for full participation of the private sector in
service delivery, based on objective criteria for certification and accreditation. The BRN
initiative aims to increase private sector participation in rural areas via PPP agreements to
ensure that at least 25% (135) of the 544 dispensaries identified will be manned with private
skilled health workers by 2017/2018.

The government will stimulate more investments in the health care industry, ranging from
infrastructure development (e.g., leasing solar power plants) to production of
pharmaceuticals and equipment, as well as human resources development, e.g., in training
institutions. The development of e-health and telemedicine will also offer investment
opportunities for the private sector. Partnerships will provide opportunities for learning
about new technologies as well as skills transfers and assist the growth of the health and
social welfare sector.

During the implementation of HSSP IV, stronger partnerships will be built with traditional
and alternative health care providers. Greater coordination will be established at all levels,
from national and regional to the council level. The main areas of partnership will be
specifically to promote awareness and accessibility to improved traditional and alternative

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health services, quality improvement, strengthened management of services, research and
improvement in the utilisation of traditional medicine research findings.

In order to achieve optimal health for the nation, it is necessary to address social
determinants of health. Many health and social welfare issues require intersectoral
collaboration with other public and private sectors (see Section 4.3). The growth of the gas,
mining, power and tourism sectors and private companies operating in those sectors offer
increased demand for health services and reciprocal ability to invest in the health
sector. The proposal to provide a MBP by a SNHI still provides space for private health
insurers to offer market niche products for companies and individuals that will mobilise
additional revenue to improve the health system. The MOHSW will also work in partnership
with the private sector to promote their corporate social responsibility to their employees
and to the communities where they operate. Currently corporate social responsibility is
voluntary but its benefits will be documented and promoted to the private sector.

7.3 Gender in Health

7.3.1 Gender Mainstreaming

Gender mainstreaming is a priority for the health and health-related sectors. The MOHSW
will enhance integration, monitoring and coordination of gender affirmative action within
the health sector and related sectors (Women, Gender, and Children, Water and Energy,
Agriculture, Education). Through the CCHP guidelines, the MOHSW will ensure gender
concerns are addressed distinctly. One of the key focus points will be to increase the
understanding of gender equity and its relation to family life improvement, using the agency
of the new CBHP which already addresses gender as a strategic area of action at community
and household levels. Orientation to a rights-based approach in health will be provided at
facility and community levels, to clarify the distinctions between rights holders, duty
bearers, and obligations for stakeholders. Through such an orientation, coupled with
application of the Client’s Charter, the health rights of women and men, adolescent girls and
boys, and health rights of youth shall be promoted and protected. The MOHSW will promote
culturally sensitive information, education and communication materials through mobile
phone applications for the health sector, to benefit maternal health and choice and access
to FP methods, in particular targeting women, girls, boys and young couples.

The MOHSW will produce further analysis of gender issues and underlying causes of
inequities, including structural, policy and budget processes, based on disaggregated
indicators in the HSSP IV or in Disease Control Programmes, or based on specific research
activities to be commissioned.

The MOHSW will support pragmatic measures for reducing Gender Based Violence (GBV) in
society as elaborated in paragraph 5.4 of this strategic plan. It will advocate for the
countrywide use of the National Management Guidelines for the Health Sector Prevention
and Response to Gender Based Violence. Through the CHMTs, it will advise LGAs on
establishing and sustaining GBV Drop-In centres building on already tested experience in the
country and tapping on local NGOs’ experience in constructive, male involvement.

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7.3.2 Gender Equity

The health sector will continue to promote gender equity, equal opportunities to access
health services for all people. In practice, it is about female empowerment in decision
making about health issues and male involvement in care for the family. The MOHSW will
conduct operational research to identify good practices and lessons learnt about promoting
gender equity, to share widely with stakeholders. The MOHSW and PMO-RALG will ensure
that governance structures (HFGCs, CHSBs, Hospital Boards etc.) and other decision-making
mechanisms have balanced representation of men and women.

The MOHSW will direct training institutions to develop distance learning initiatives to tackle
gender and health issues, such as gender equity and gender affirmative action. Such
initiatives could be delivered intermittently through the use of mobile phones and other ICT
channels to reach all RHMTs, CHMTs and health facility staff.

7.3.3 Equity

In the health and social welfare sector, equitable service provision will remain apriority,
giving preference to those in the society who are most vulnerable, living in remote area and
in the poorest Councils. Targeted interventions under different departments are designed
according to the needs. The risk pooling under Health Insurance provides for gender equity
by design, where the package covers households inclusive of both men and women. The
anticipated SNHI and its MBP shall guarantee access to individuals that would be unable to
pay (often women without means of earning income).

7.4 SWAp Co-ordination and Management

The Sector Wide Approach (SWAp) facilitates coordination and collaboration among
stakeholders within the health sector in Tanzania since 1999. Stakeholders include the
MOHSW, PMO-RALG, MOF, NGOs and civil society, private sector, and development
partners, including UN Agencies, active in health. It aims to create synergies and reduce
transaction costs through coordinating financing, planning and monitoring of all health
interventions, on and off-budget, in line with the alignment and harmonisation policy
framework.

The 2007 Code of Conduct for the SWAp set out expectations and commitments of all
parties based on the principles of the Joint Assistance Strategy of Tanzania (JAST). The
Government of Tanzania is in the process of finalizing a new Development Cooperation
Framework (DCF) to replace the JAST with a greater role for civil society and the private
sector as well as emerging development partners. Under the new DCF the Health Sector
Working Group (HSWG) will continue to promote a sector wide approach (SWAp) to health.

At the national level coordination of the Health SWAp will be through the following:
 Health Sector Working Group (HSWG)
 Health Sector Technical Committee (HSTC) (replacing the TC SWAp)
 Technical Working Groups (TWG)

Coordination and management of the SWAp at regional and council level will also be
strengthened through use of the recently approved Regional and Council Health Technical
Committee structures. Linkages will also be strengthened with the governance structure of

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the Tanzania National Coordinating Mechanism (TNCM) for financing through the Global
Fund to fight AIDS, TB, and malaria, and other health related constituent groupings such as
the Development Partner Group for Health (DPG-H), Development Partner Group for AIDS
(DPG-AIDS), the Joint Thematic Working Group on HIV & AIDS, the Public Private Health
Forum (PPHF), the Policy Forum, and other groupings that emerge and that are seen as
strategic partners to the health SWAp. The reporting relationship between the SWAp
governance and the institutional structures of Government will also be strengthened. A
special emphasis will be on incorporating new initiatives into the SWAp governance
structure that aim to accelerate the progress of the sector such as the BRN, RBF, etc. Figure
9 below provides a summary of the SWAp governance structure.

Figure 9 Health SWAp Coordination Structure and tentative linkages

The Health Sector Working Group (HSWG) will provide a platform for sector dialogue among
relevant stakeholders under Government leadership on national health policies, strategies
and plans. The HSWG membership shall include MOHSW, PMO, TACAIDS, PMO-RALG, MOF,
PO-PSM, development partners, private sector, NGOs and Civil Society. The Health Sector
Reform Secretariat (HSRS), Department of Policy and Planning will act as secretariat to the
HSWG.

The HSWG will meet biannually during the Annual Sector Planning Meeting (ASPM). It will
review the annual sectoral work plans and budgets and the general progress on
implementation of the HSSP. It will also discuss other relevant topics like the findings of the
Health Sector Public Expenditure Review, Summary Audit Reports, etc. The Joint Annual
Health Sector Review (JAHSR) will provide the overall policy direction for the sector and
mobilise resources for the sector. The JAHSR will approve the sector policy priorities for the
coming financial year and undertake advocacy for the sector and resource mobilization
efforts for the sector including GOT budget commitments.

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In addition the HSWG will provide the link to the Cluster Working Groups under the DCF and
ensure efficient and effective coordination with all stakeholders through inter-sector
collaboration and coordination.

The Health Sector Technical Committee (HSTC) will have a advisory role; it will advise senior
management of government on technical issues of the HSSP IV and it is related more specific
strategies and plans. The HSTC will promote coordinated and coherent technical support and
policy dialogue. The members of the HSTC will be a selection from HSWG. The HSRS will
provide secretariat support. The HSTC will link with the TCs at Regional level.

The Health Basket Financing Committee (HBFC) comprises of representatives of the

MOHSW, PMO-RALG, MOF and basket-DPs. The HBFC is responsible for overseeing
operation of the joint funding mechanism, including approving the release of resources
against the HSSP, MTEF and CCHPs and ensuring that the use of basket resources follows set
financial, administrative and management procedures.

The Technical Working Groups (TWG) will be regrouped for a high level of joint planning,
coordination and monitoring of specific investments in the sector. The number and theme of
the TWGs will be proposed by the HSTC and decided by the HSWG. All TWGs will report to
the HSWG through the HSTC. TWGs shall meet monthly and hold ad hoc meetings as
required.

The Regional and Council Management Teams (RHMT) will operate through Management
or Governance Committees (chaired by RMOs and DMOs respectively) and Regional and
Council Technical Committees (co-chaired by the Hospitals’ in-charges and epidemiologists).
These will bring together sector partners operating within the Regions and Councils.
Membership and Terms of Reference shall be similar to those of the HSTC.

Within the Ministry of Health and Social Welfare, the Senior Management Committee (SMC)
is responsible for overseeing the implementation of the programme of work as detailed in
the HSSP IV and will review and approve all budgets, plans and reports before submission to
the HSWG. On a monthly basis the DP-Troika will be invited to join the SMC to discuss critical
issues relating to the implementation of the HSSP IV programme of work.

The Development Partners Group for Health (DPG Health), a collection of bi-lateral and
multi- lateral agencies supporting the health sector in Tanzania, will continue to provide a
platform for dialogue among development partners, with a three person lead arrangement
(Troika). The Troika will continue to represent the DPG Health at high level sector dialogue
meetings, with opportunities for individual partners to participate in TWGs in areas of
specific interest.

The Development Partners Group for AIDS (DPG AIDS), a collection of bi-lateral and multi-
lateral agencies supporting the multi-sectoral national response to HIV and AIDS, will
continue to provide a platform for dialogue between development partners and TACAIDS.

The Public-Private Health Forum (PPHF) was launched in 2014 to improve public-private
dialogue in the sector. The PPHF is working to organise the private sector into
representatives of different constituents engaged in health and social welfare in Tanzania,
ranging from service providers, NGOs, Civil Society, professional bodies, private medical
training institutions, manufactures, insurance companies, etc. Strengthening the linkages
between the PPHF membership and the SWAp coordination arrangements will further
enhance the sector dialogue and will increase the breadth and depth of the SWAp

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In 2007, the MOHSW, PMO-RALG, MOF and Development Partners developed and signed a
Code of Conduct to facilitate an effective partnership between government and developing
partners in the health sector. A new Code of Conduct will be developed in line with the
structures outlined in Figure 9 above and will include the wider partnership of civil society
and the private sector.

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8 Resource Planning for HSSP IV
Estimates of the financial resources required and available in the health sector are needed
to guide implementation of the HSSP IV. This Section shows the estimated costs, fiscal space,
and funding gap from 2015/2016 to 2019/2020.

8.1 Resource Needs

8.1.1 Methodology

The One Health Tool, a model for medium- to long-term strategic planning in the health
sector, was used to estimate the costs of the HSSP IV. The tool estimates the normative
costs of health programmes, comprising of commodity and programme support costs, as
well as the resource needs of health system components, including infrastructure, human
resources for health, logistics, health information systems, health financing, and governance.
MOHSW staff, clinicians, regional and district medical officers, and staff from other
organisations in the health sector, such as MSD, provided all cost assumptions. Data from
individual strategic plans, HMIS, demographic and health surveys, and other health and
disease-burden studies informed the development of assumptions. The cost results include
BRN implementation costs and service delivery costs borne in both the public and private
health sectors.

8.1.2 Total resource needs

The five-year cost of the HSSP IV is estimated to be TZS 21,945 billion. Costs increase each
year from TZS 4,013 billion in 2015/2016 to TZS 4,859 billion in 2019/2020. This is equivalent
to a stable per capita expenditure of around US$ 42. Increase in costs keeps pace with
population increase. The costs by programme area and health system component are shown
in Table 5 below. Approximately half of the HSSP IV financing requirement is related to
health services, and another half relates to health system costs.

Table 5 HSSP IV costs (TZS billions) by programme and health system component

2015/2016 2016/2017 2017/2018 2018/2019 2019/2020

Programmes, interventions and services
HIV/AIDS 602 598 594 630 644
NCDs and mental health 340 415 499 585 674
Malaria 260 188 186 185 185
Maternal, newborn, and
139 153 158 171 169
reproductive health
Immunizations and vaccines 126 120 116 105 97
Oral care 134 146 158 172 188
General health services 130 132 135 137 139
Child and adolescent health 82 103 115 131 127
Tuberculosis and leprosy 92 121 112 113 119
Environmental health 50 43 49 43 43
Orthopaedic and trauma
40 41 42 43 43
services

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 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020
Neglected tropical diseases 27 24 20 19 20
Department of Social
14 15 17 21 23
Welfare
Ophthalmology 5 5 4 3 3
Nutrition* 4 5 5 5 6
Health promotion 4 4 4 2 2
Alternative and traditional
1 0.4 0.4 0.3 0.3
medicine
Subtotal (TZS billion) 2,054 2,112 2,214 2,366 2,481
Health systems
Human resources 740 807 879 948 1,034
Infrastructure 590 610 574 548 565
Logistics^ 388 414 440 469 509
Governance 117 119 124 120 134
Health financing 92 34 51 78 74
Health information systems 33 35 76 54 63
Subtotal (TZS billion) 1,959 2,020 2,145 2,217 2,377
Grand total (TZS billion) 4,013 4,133 4,359 4,582 4,859
Grand total (USD million)~ $1,942 $2,000 $2,110 $2,218 $2,352
USD per capita $36 $36 $37 $38 $40
*Some nutrition costs are included in maternal and child health. For the complete costs of nutrition interventions
and programs, see Annex 2.
^Logistics costs include the costs of freight, insurance, clearance, quality assurance, procurement, storage and
distribution, and wastage for all commodities.
~Using the exchange rate of 2065.95 TZS per 1 USD.
Note: Subtotals and grand total are subject to rounding.

8.1.3 Costs of health services

The five-year cost of programmes, interventions and services is TZS 11,226 billion, with costs
increasing from TZS 2,054 to 2,481 billion from 2015/16 (Year 1) to 2019/2020 (Year 5). This
financing requirement includes commodity and programme management costs for 228
interventions (note: the commodity costs do not include any logistics costs). Programme
management costs decrease from TZS 573 to 480 billion from 2015/2016 to 2019/2020 due
to front-loaded investments in training programmes and other support activities in HSSP IV.
Commodity costs, exclusive of logistics (procurement and supply chain management and
other costs); represent 78% of the financial requirements for health services and increase
from TZS 1,480 to 2,001 billion by the end of the HSSP IV period.

Commodity costs that are earmarked for vertical programmes and primarily financed
externally (i.e., commodity costs for HIV/AIDS, immunisation, malaria, TB/L, and NTDs)
account for TZS 761 billion (Year 1) and remain much the same in Year 5 at TZS 772 billion.
Costs for RMNCAH commodities and other essential medicines and health products are TZS
718 billion in Year 1, increasing to TZS 1,230 billion in Year 5. However, unlike the disease
control programmes, commodities for these general services and integrated programmes
are probably substantially underfunded, and consequently these interventions may be
“under-treated” at the baseline of HSSP IV.

The commodity costs reflect the MOHSW’s prioritised scale-up of health interventions given
the fiscal space and health system constraints. Through a multi-stakeholder process, the
MOHSW identified high-priority interventions to scale-up for maximum health impact and
lower-priority interventions, which will have flat coverage from 2015/2016 to 2019/2020.

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About half of the 228 interventions in the costing are scaled-up in full. If all interventions
were scaled-up according to programmes’ ambitions, the HSSP IV would require TZS 2,546
billion more for commodities, including wastage, freight, clearance, and quality assurance.

Two disease control programmes (HIV/AIDS and NCDs including mental health) account for
nearly half of total health service costs. The HIV/AIDS resource requirements take into
account that 90% of all people living with HIV will receive ART by 2020.The cost analysis
assumes the prevalence of NCDs will increase over time, resulting in increased need of
preventive and curative NCD services. Other key health service targets used in the cost
analysis are included in Annex 2.

8.1.4 Costs of health systems

The five-year cost of health system components totals TZS 10,719 billion, with costs
increasing from TZS 1,959 to 2,377 billion from 2015/2016 to 2019/2020. Financial resource
requirements are greatest for human resources for health. By the end of the HSSP IV, there
will be an estimated 108,635 human resources for health in the country, including 5,000
formalised community health workers. Infrastructure resource requirements, which include
operating and capital costs of facilities and vehicles, peak in 2016/2017 as new construction
will not begin until that year. From 2015/2016 to 2019/2020, 834 and 5,783 facilities will be
constructed and rehabilitated, respectively. (See Annex 2 for more information.)

The remaining health system components represent about 16% of the total HSSP IV costs.
Logistics costs explicitly capture MSD’s operating costs, which cover the procurement and
supply chain management costs in-country, as well as the cost of commodity wastage,
freight, clearance, and quality assurance (note: MSD’s working capital is not included in the
costing). Governance includes management and governance activity costs for multiple
government actors across different levels of the health system (e.g. MOHSW, PMO-RALG,
RHMTs, and CHMTs). The costs of RBF and implementation of a SNHI are under the health
financing resource requirements. Health information systems comprise the costs of
electronic and paper-based M&E systems, including investments in ICT at the facility level.

8.2 Available Resources

Fiscal space for health can be defined as the combined potential annual financial resources
that can be mobilised across government, development partners, health insurers, individual
and corporate philanthropy, and households’ own expenditure out-of-pocket (distinct from
purchasing health insurance). Combined with resource need estimates from section 8.1,
such analysis can help to determine if current sources of financing health will be sufficient or
if new sources or new efficiencies must be found, and whether scale-up targets should be
adjusted. Fiscal space analyses should be regularly updated, utilising the insight from
extrapolation of actual trends. New analyses should also be responsive to potential
opportunities for other sources and innovation. A fiscal space analysis for the Tanzanian
health sector was conducted in 2014. However, given proposed reforms to the health
financing structure (section 6.6), availability of new data and discussions on innovative
sources, a revision was required. This section provides a summary of the revised fiscal space
analysis, with further details in Annex 2.

A detailed macroeconomic model was built for years 2014/15 to 2019/20 and data from
bilateral as well as health basket fund partners were used to disaggregate all on-budget and
off-budget funding sources. Sources such as domestic allocation to health via MOHSW,
Regions, and specifically for recurrent and development heads were projected. LGA revenue

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and allocation to health were also estimated. Moderately ambitious targets were set for
allocation to health from such sources, where required. Analysis was based on scenarios,
e.g., an ambitious scenario – incorporating innovative financing sources – as well as a
baseline scenario for the continuation of current trends. Within the ambitious scenario, two
options being considered for SNHI contributions (see section 6.6) were further explored.

Figure 10 Ambitious Scenario for Fiscal Space, with Higher Contributions for SNHI

However, the future fiscal space may be more constrained if optimistic forecasts and
innovative sources are not realised or if the SNHI is not promulgated during the HSSP IV
period. Figure 11 shows the different possibilities in terms of the scenarios. Without the
SNHI or innovative financing as a proportion allocated to health from sources such as sin
taxes, ability to tap the retained revenues of parastatal bodies, and taxes on mobile
communication, the fiscal space is significantly smaller.

Figure 11 Comparison of Scenarios showing Impact of Innovative Financing and SNHI

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8.3 Funding Gap

The difference between the estimated fiscal space and costs reveals the potential funding
gap for implementing the HSSP IV. The fiscal space analysis did not explicitly model out-of-
pocket payments (OPP), meaning that some of the funding gap could be partially understood
as OPP. However, the funding gap indicates the additional financial resources that need to
be mobilised in order to meet the HSSP IV targets.

Figure 12 shows the funding gap each year by comparing the HSSP IV costs to the highest
fiscal space scenario as a percentage of GDP. The estimated funding gap in 2015/2016 is TZS
1,354 billion. Under the most ambitious fiscal space scenario, the funding gap will increase
from TZS 511 billion in 2016/2017 to TZS 1,493 billion in 2019/2020. Without innovative
financing sources or SNHI, the funding gap could be as large as TZS 1,406 billion in
2016/2017 and grow to TZS 2,421 billion by 2019/2020.

Figure 12 Estimated Resources Needed vs. Available as Percentage of GDP

The funding gaps can only be overcome by OPP, increased Government funding, or
postponement of ambitions laid down in this HSSP IV document. Innovative funding will only
come in during the next fiscal years. DPs are reducing their commitments rather than
increasing them and will probably not fill the gap.

It is clear that the ambitions of HSSP IV are beyond the predictions of the most optimistic
scenario of the HFS. If Government increases its commitment to the health sector compared
to the historic trend, ambitions may be realised. The annual update of the fiscal space
analysis should go hand in hand with an annual review of the ambitions and performance
targets for the health and social welfare sector. Ambitions should be adjusted to what is
realistically feasible within the available resources for the sector.

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9 HSSP IV Performance Assessment and Follow Up
9.1 Introduction

The MOHSW is using the following framework for HSSP IV Performance assessment and
follow-up, which includes a standardised and shared approach as to how M&E will be
conducted. This framework is supported by M&E strengthening, nationally agreed upon
HSSP IV indicators and M&E for the implementation of HSSP IV. Monitoring HSSP IV is
narrowly connected to monitoring performance of the health sector as a whole, as will be
elaborated below.

Figure 13 HSSP Performance Assessment and Follow-Up

The HSSP IV M&E framework has two time horizons and two types of indicators. One
provides a long-range view of 10-20 years across several strategic planning cycles and
focuses on indicators of sustained improvement in health of the population (e.g., life
expectancy, mortality). The second time horizon provides a midrange view of 5 years over
the lifetime of a single health sector strategic plan and focuses on indicators required to
monitor the service delivery or programme implementation as described in the HSSP IV
strategic plan (e.g., attendance rates, cure rates, nutrition status, implementation of
activities).

A third monitoring perspective concerns whether changes in the indicators correspond to

the health sector's specific objectives as formulated in Section 4.3. For example, are there
improvements in quality, equity, and accountability in the health sector?

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The indicators and monitoring modalities have been selected to accord with three priorities:
national priorities, international priorities (SDGs), and M&E priorities. National priorities
include the strategic health and service issues and initiatives identified in this document, the
strategic objectives of the health sector, and alignment of national initiatives, including both
programmes and cross-cutting initiatives, such as BRN, HBF, RBF, and the CCHPs.
International priorities include the requirements of various international agreements,
including the successor to the MDGs: the SDGs. M&E priorities include the selection of
parsimonious and multipurpose indicator sets consistent with, and drawn from, existing
health information systems, and the provision of timely and quality information on demand
– when needed, with multiple visualization options: tables, charts, maps.

9.2 Monitoring Health and Social Welfare Performance

Health sector performance indicators are reflected in detail in Annex 3. The 64 indicators
include 43 routinely collected input, output, and outcome indicators that can be monitored
annually and usually quarterly or monthly. The performance indicators are monitored
annually through a report prepared by the MOHSW and reviewed by stakeholders at the
JAHSR; 10 of these can also be measured by survey, which provide a population-based
calibration of facility-based indicators and often reflect equity stratifications by socio-
economic characteristics. Population-based health status, fertility, and mortality rates are
measured by 21 survey or census indicators that reflect impact and policy goals; some of
these can be compared with annual rates obtained through IHI’s Sample Vital registration
with Verbal autopsy (SAVVY) system. The Sentinel Panel of Districts (SPD) reflects national
trends and provides morbidity and mortality estimates.

In addition to monitoring overall performance, indicators that reflect the performance of

several initiatives can be used to compare the effects of these initiatives. For example,
facilities that implement RBF can be compared with those that do not, or performance of
facilities that implement both BRN and RBF can be compared with those that implement
only one or neither. Before and after performance comparisons can also be made.

Table 6 Selection of Health Sector Performance Indicators from HMIS (full list Annex 3)

No Description
1 Antenatal care coverage: before 12 weeks gestational age
2 Institutional delivery coverage
3 Vaccination rate: measles under one year
4 Vitamin A supplementation coverage
5 Children under 5 who are stunted
6 Prevention of Mother-to-Child Transmission
7 Confirmed malaria cases
8 Case detection rate for all forms of tuberculosis
9 Children among newly detected leprosy cases
10 Cervical cancer screening
11 Availability of Medicines and Health Products
12 Outpatient attendance.
13 Completeness of HMIS report

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9.3 Monitoring HSSP IV implementation progress
9.3.1 BRN Monitoring

Monitoring HSSP IV implementation requires tracking progress towards the objectives of

BRN, programme, and sector-wide initiatives singled out for special attention in the HSSP IV
strategy. The BRN provides both a challenge and an opportunity. The challenge is to provide
accurate and consistent information, processed and analysed in a timely fashion, for regular
review at the highest levels – weekly by senior MOHSW and PMO-RALG managers, monthly
by the Ministerial Delivery Unit (MDU), chaired by Minister of MOHSW, and quarterly by
Presidential Delivery Bureau (PDB).

The opportunity is for MOHSW to take the BRN monitoring process as an example of best
practice. It uses a framework of well-defined quantifiable indicators for internal monitoring
of the implementation progress. In the BRN framework the four KRAs have top line Key
Performance Indicators (KPI) showing the expected health sector results. In turn, each KRA
comprises four to six initiatives, which measure attainment of their objectives through their
own KPIs. Each of these 22 initiatives comprises a series of activities (tasks) that come
together to produce the results expected through the initiative and reflected in its KPI. (See
Section 2.2.3 for details.) The top line and initiative KPIs are reviewed sometimes weekly,
and always monthly and quarterly at national and sub-national levels. This BRN framework
provides a model for monitoring HSSP IV implementation in other areas.

The HSSP IV plans to take the National Key Performance Area in Health (BRN) countrywide
after 2018, and therefore the Key Performance Indicators will have a countrywide coverage,
not only restricted to the identified BRN Regions.

Table 7 Top Line key indicators for BRN

Number Indicator or Target

HRH 1 All Regions at or above 2013/2014 National Average
(Density of Skilled HRH/10k population at primary care level)
HRH 2 Percentage utilisation of employment permits for HRH
HRH 3 70% reduction in the number of facilities without Skilled HRH nationwide
Performance 1 80% of health facilities rated at level 1 Star rating and 2 in 12 regions identified and
elevated to level 3 Star rating and above by June 2018.
Performance 2 80% of health facilities to achieve 75% and above customer satisfaction by June
2018.
Performance 3 80% of health facilities use facility funds (self- generated and allocated) for
improving service delivery by June 2017
Performance 4 80% LGAs have functioning social accountability mechanisms by June 2017
Medicines 1 Stock availability (HMIS)
Percentage of facilities with availability of each key medicine
Percentage of facilities with availability of all 10 key medicines
Medicines 2 Order fill rate
Percentage of items ordered that are actually received by HF
RMNCAH 1 Percentage of pregnant women attending ANC first visit by 12 weeks
RMNCAH 2 Percentage of pregnant women attending ANC 4 visits
RMNCAH 3 Percentage of deliveries by SBA
RMNCAH 4 Percentage of Institutional deliveries
RMNCAH 5 Percentage of PNC (2/7 days) for mother
RMNCAH 6 Percentage of PNC (2/7 days) for newborn

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9.3.2 Monitoring Achievements of Specific Objectives of the HSSP IV

HSSP IV has five specific objectives, which can be summarised as follows:

1. Quality Improvement of primary health care and delivering of a MBP
2. Equitable access to services, based on geographical and vulnerability criteria
3. Community partnership in service delivery and management
4. Effective management and innovative partnerships
5. Addressing social determinants of health through intersectoral collaboration

Table 8 Indicators for Measuring Performance of Specific Objectives

Specific Objectives Areas where Indicators can be derived from

Quality and Essential Package Star Rating, Service Utilisation Figures, Facilities Staffing,
Medicines Availability, Social Welfare Utilisation
Equity and Accessibility Health Facility Network Coverage, BEmONC and CEmONC
coverage, HRH distribution, CHW coverage, RMNCAH &
RBF, Gender disaggregated utilisation
Community Partnerships Community Health Programme performance, CHW
coverage, HFGC performance, CHSB performance,
Community Score Cards
Effective Management and Innovative CCHP performance, Financial Management health
Partnerships Facilities, MSD performance, HMIS performance, Service
Agreements, Contractual Arrangements, Financial
Indicators
Social Determinants of Health Nutrition indicators, Health Impact Assessments, Water
and Sanitation, School Health Programme, Road Safety,
Participation Vulnerable Groups, School Disabled Children

The Health Sector Performance Indicators and the BRN-KPIs will contribute to measuring
progress of the specific objectives indicators (shown in Annex 3 and 4). In addition more
qualitative process indicators will be used for certain HSSP IV activities. Annex 5 shows
qualitative indicators for specific objectives as reflected in the HSSP IV, in addition to the
health sector performance indicators and BRN KPI. Indicators in Annex 5 are comparable
with milestones used previously in JAHSRs.

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Figure 14 Annual progress monitoring using indicators from sets

The Health Sector Technical Committee will select annually from the three indicator sets
those indicators that will be monitored specifically, related to the action plans and proposed
milestones for that year. These indicators will be reviewed in the JAHSR to assess progress of
the implementation. See figure 14 above for the indicator sets, which feed into the annual
review process.

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10 Assumptions and Risks

Political stability and commitment: Tanzania has known decades of political and social
stability. The assumption that it will continue like this is fair. The Government approach in
BRN, with emphasis on performance and accountability, is likely to make a positive impact
on the health sector. In BRN, the government has expressed commitment towards a
prioritised approach to health services (targeting under-served regions and vulnerable
groups. It is assumed that this is sustained and embedded across the system.

Resource allocation: Tanzania has experienced strong economic growth over the past
decade and prospects for further growth are positive. However, the economic developments
have not yet translated into increased availability of resources for health. It is assumed that
in the HSSP IV period the health sector will benefit more from available resources due to
economic growth. At the same time, the trend of dwindling external support to the health
sector is likely to continue. To mitigate the effects of low resource allocation the sector will
focus on better prioritisation, higher efficiency and on curbing corruption and pilferage. The
HFS suggests innovative methods of resource mobilisation. HSSP IV has defined its ambitions
knowing that there is a funding gap. Annual review of the funding gap and adjustment of the
ambitions will enable the health and social welfare sector to formulate realistic annual
targets.

Natural disasters and epidemics: Recent history has shown the high risks of natural disasters
and epidemics in Africa. Tanzania is building up its resilience by strengthening food security,
addressing vulnerable regions and populations (e.g., in the BRN programme) and by stepping
up the Epidemics Preparedness and Response.

Availability of human resources: The health sector depends mainly on the availability of
human resources. It competes with other sectors to get the best people to join the
workforce. Salaries, working conditions and career perspectives must be attractive to get
those people. On the one hand the redistribution of health workers and compulsory
attachments may reduce attractiveness of the health sector; on the other hand performance
management systems and incentives may attract more people to work in the health sector.
Good human resources management is crucial in addressing availability of HRH.

Commitment of the population to health: Increasingly in Tanzania, there is an appeal to the

population to take responsibility for health matters, in terms of paying for insurance,
financing for health interventions, in terms of adopting preventive health activities, and in
terms of participating in management of health facilities. Trust is extremely important.
Measures regarding community accountability and transparency should build and maintain
trust of the population.

86
Annex 1 Background Documentation
General
Health Acts
Tanzania Food, Drugs and Cosmetics Act No. 1 of 2003
Tanzania Food, Drugs and Cosmetics Act No. 1 of 2003
Tanzania Food, Drugs and Cosmetics Act No. 1 of 2003
The Disabled Persons (Care And Maintenance) Act, 1982
The Environmental Health Practitioners (Registration) Act, 2007 - (Act No. 20/07)
The HIV and AIDS (Prevention and Control) Act, 2008 (Act No. 28/08)
The HIV and AIDS (Prevention and Control) Act, 2008 (Act No. 28/08)
The Health Laboratory Practitioners Act, 2007 - (Act No. 22/07)
The Health Laboratory Technologists Registration Act, 1997
The Human DNA Regulation Act, 2009
The Medical Radiology and Imaging Professionals Act, 2007 - (Act No. 21/07)
The Mental Health Act, 2008
The National Health Insurance Fund Act, 1999
The Pharmacy Act, 2002 - (Act No. 7)
The Private Health Laboratories Regulation Act 1997
The Protection From Radiation Act, 1983
The Public Health Act, 2009
The Tanzania Commission for AIDS Act, 2001 - (Act No.22)
The Tanzania Food, Drugs And Cosmetics Act, 2003 Fees Regulations
The Tanzania Food, Drugs and cosmetics Act, 2003
The Tobacco Industry Act, 2001
The Tobacco Product (Regulation) Act, 2003
The Tobacco Product (Regulation) Act, 2003
The Traditional and Alternative Medicines Act, 2002

Quality
Title of document Period
National Health and Social Welfare Quality Improvement Strategic Plan: 2013- 2013
2018 (2013)
Tanzania Quality Improvement Framework, 2nd edition 2011-2016 (2011) 2011
National Infection Prevention and Control Guidelines for Healthcare Services in 2004
Tanzania, MoHSW (2004)
National Infection Prevention and Control Pocket Guide for Healthcare Services 2007
in Tanzania, MoHSW (2007)
MwongozowaTaifawaKukinganaKudhibitiMaambukizokatikaUtoajiwaHudumaza 2007
Afya: Kiongozi cha Mfukoni kwa Watoa Hudumaza Afya Tanzania, MoHSW
(2007)
National Infection Prevention and Control Standards for Hospitals in Tanzania, 2012
MoHSW (2012)
National Communication Strategy for Infection Prevention and Control 2012- 2012
2017, MoHSW (2012)
National Guidelines on Post-Exposure Prophylaxis following Occupational and 2014
Non Occupational Exposures to Blood and Other Body Fluids, MoHSW (2014)
National Recognition Guidelines for Health Care Quality Improvement Programs, 2014
MoHSW (2014)
Implementation Guidelines for 5S-CQI-TQM Approaches in Tanzania: 2013
“Foundation of all Quality Improvement Programme” MoHSW, Third Edition

87
Title of document Period
(2013)
Mwongozo wa Utekelezaji wa Njia za S5-UUE(KAIZEN)-UUU Tanzania “Msingi wa 2013
Programu zote za Uimarishaji Ubora,” MoHSW (2013)
National Supportive Supervision Guidelines for Healthcare Services, MoHSW 2010
(2010)
Quality Improvement – Infection Prevention and Control Orientation: Guide for 2009
Participants, MoHSW (2009)
National Guidelines for Safecare Standards for Dispensaries, Health Centers and 2014
District Hospitals (2014)
National Guidelines on Quality Improvement of HIV and AIDS Service 2010
A Manual for Comprehensive Supportive Supervision and Mentoring on HIV and 2013
AIDS Services
Tools for Supportive Supervision and Mentoring of HIV and AIDS Services 2013

Council Health Care

Title of document Period
Planning template for developing Dispensary and Health Centre plans 2009
Comprehensive Council Health Planning Guideline for Local level 2011
National Essential Health Care Interventions Package – Tanzania (NEHCIP – Tz) 2013
Primary Health Services Development Programme- MMAM 2007- 2017 2007 - 2017
Council Health Services Board 2013

Hospital Care
Title of document Period
Guideline for Reforming Hospitals at Regional and District level 2005
Training Modules on Management of and district and Regional Referral 2010
Hospitals: Module one : Quality Health Care in Hospitals
Training Modules on Management of Regional Referral and district Hospitals 2010
Module Management of Hospital Services
Training Modules on Management of Regional Referral and district Hospitals 2010
Module: Planning module 2010
National Essential Health Care Interventions Package (NEHCIP) 2013
Comprehensive Council Health Plan Guidelines June 2011
Planning CHOP template 2010
Guideline for implementation of 5S KAIZEN –TQM MoHSW 2014 - 2019
Functions of Regional Health Management System 2008
Tanzania Quality Improvement Framework 2014 -2016

Regional Health Management Team

Title of document Period
Functions of Regional Health Management System 2014-2019
RHMT Planning and Reporting Guideline 2014-2019
Regional Management Supportive Supervision to Councils (RMSS-C) 2014-2019
Regional Management Supportive Supervision to Regional Referral Hospitals 2014-2019
(RMSS-H)

Services Delivery
Reproductive Maternal Newborn Child & Adolescent Health
Title of document Period
National Guideline for Comprehensive Care services for Prevention of Mother to Sept, 2013
Child Transmission of HIV and Keeping mothers Alive
Tanzania Elimination of Mother to Child Transmission of HIV Plan, 2012 – 2015 2012 - 2015

88
Title of document Period
National Communication Strategy for the Elimination of Mother to Child Transmission 2014 - 2017
of HIV (e-MTCT)
The National Road Map to accelerate reduction of Maternal, Newborn and Child 2008-2015
deaths in Tanzania 2008-2015
National Roadmap Strategic Plan to Accelerate Reduction of Maternal, Newborn and 2014
Child Death 2008 – 2015, Sharpened One Plan, MOHSW, 2014
National Cervical Cancer Prevention and Control Strategic Plan 2011-15
Tanzania Delivery Guidelines for Cervical Cancer Prevention and Control, MOHSW 2010
National Adolescent Reproductive Health Strategy 2010 – 2015
National Family Planning Costed Implementation Programme 2010 – 2015
National Operational guidelines for Integration of Maternal, Newborn, Child Health 2012
and HIV/AIDS services in Tanzania
Tanzania National Family Planning Research Agenda 2013- 2020
National Family Planning Guidelines and Standards 2013
National Family Planning Outreach guidelines 2014
Tanzania National Family Planning 2020 Action Plan 2013
National package of Essential Family Planning Interventions for CCHP 2014
National Communication Strategy for MNCH 2011 – 2015
National Policy Guideline for Health Sector Prevention and response to Gender-based 2011
Violence
National Integrated Community MNCH Guidelines, MOHSW, 2012
National Package of Essential Reproductive and Child Health Interventions
National Policy Guideline for Reproductive and Child Health 2003
National Kangaroo Mother Care Guideline 2008
National Paediatric Standard Treatment guideline 2014
National Postpartum Care guidelines 2011

HIV/AIDS
Title of document Period
Draft HIV Policy
Health Sector HIV Strategic Plan III 2013-17
2 year Operational Plan for implementation of Health Sector HIV Strategic Plan III 2013-15
eMTCT Plan 2012-15
Draft VMMC Country Operation Plan 2014-17

Malaria
Title of document Period
Malaria Strategic Plan 2014-2020
Business Plan 2013/14-
2015/16
Monitoring and Evaluation Plan 2014 -2020
National Guidelines for Diagnosis & Treatment of malaria Version 2013
Integrated Malaria Vector Control Guidelines Version 2014
Malaria Communication Guidelines Version 2014
Malaria Partners’ interventions oversight Plan Version 2014
Malaria resource Mobilisation Plan

Tuberculosis
Title of document Period
National TB and Leprosy strategic plan IV 2009 -2015
Draft National TB and Leprosy strategic plan V 2015-2020
National Policy Guidelines for Collaborative TB/HIV activities, 2007
National TB and Leprosy Programme, Advocacy Communication and Social 2013

89
Mobilization Strategy,
National Operational Guidance on Integrating community based TB activities in the 2012
work of NGOs and CSOs,

Neglected Tropical Diseases

Title of document Period
Strategic Master plan for the neglected Tropical diseases 2012 - 2017

Nutrition
Title of the document Period
Food and Nutrition Policy 2009
National Nutrition Strategy 2011 - 2016
TFNC Strategic Plan 2013 - 2018
Infant and Young Child Nutrition Strategy 2014
Infant and young Child Feeding National Guidelines 2013
Social Behavioral Change Communication (SBCC) 2013 - 2018
National Fortification Guidelines and Standards on wheat and maize flour edible oil 2011
National Vitamin A guideline 2011
National Micronutrient powders (MNP) guideline 2012
Districts Nutrition Plans and budget
National guidelines on Management of acute malnutrition
National Nutrition Survey (SMART methodology) 2014
Tanzania Demographic and Health Survey 2010

NCDs
Title of Document Period
National Eye Care Program Strategic Plan 2011-2016
National Strategy for Non Communicable Diseases 2009 – 2015
National Guideline for prevention and control of Non Communicable Diseases 2007
National Road safety Policy September
2009
Strategic Oral Health Plan 2012 - 2017
National Cervical Cancer Strategy
National Tobacco Control Strategic Plan 2010-2015
National Alcohol Policy Guideline
National Mental Health Policy Guideline

Emergency Preparedness
Title of document Period
Emergency Operations Guideline 2013
Mass Casualty Management Guideline 2013
Health Sector All Hazard Emergency preparedness and Response Plan 2010
Mass casualty management Training Manual 2014
Regional and District Health Disaster Management teams Guideline 2014
Disaster Risk Management Country Capacity Assessment Report 2012
Disaster Risk Management Roadmap 2012
National Chemical Emergency Preparedness and Response Plan
Nutritional Emergencies preparedness and Response Plan
Tanzania Emergency preparedness and Response Plan 2012
National Operations Guideline 2003
National Disaster management Policy 2011
Tanzania Disaster Communication Strategy 2012

90
Surveillance
Title of document Period
Public Health Act 2009 2009
IHR 2005 Core Capacity Assessment 2010
National IDSR guidelines 2011
National Avian and Pandemic l Influenza Emergency Preparedness and Response Plan 2010-2014
National IHR 2005 Action Plan 2014-2016
National Rift Valley Strategic Plan 2010-2014
National Health Laboratory Strategic Plan 2009-2015
Framework for cross border Surveillance and Response 2012

Health Promotion
Title of document Period
The National Policy guidelines for Health Promotion
The National Strategy for Health Promotion
The National Policy Guideline for Community Health Services
The National Strategy for Community Health Service
Guideline for planning and budgeting for health promotion at council levels
MOU between MOHSW, MUHAS and JHU in support of harmonized and sustainable
CHW initiatives in TZ
Advocacy toolkit for community health services
MOU between the MOHSW and TCDC in strengthening health communication

Water and Sanitation

Title of document Period
The Draft Sanitation and Hygiene Policy draft
National Environmental Health Hygiene and Sanitation Strategy (NEHHSAS), 2007/15 2007-2015
National Action Plan for Health Care Waste Management 2009-2013
National Policy Guidelines for Health care Waste Management 2006
National Standards for Health Care Waste Management 2006
National Catalogue for Health Care Waste Management 2006
National Community Led Total Sanitation Facilitation Guideline 2012
National Sanitation Option and Construction Guidelines 2012
National Sanitation Campaign Implementation Guideline 2014
The strategic plan II for the prevention and control of workplace HIV, TB and HBV for 2013-2017
Health Workers at their workplaces
Sanitation Options User Guide 2014
The Sanitation and Hygiene Operational Memorandum of Understanding 2011
International Health Regulation, 2005 2005
Guide to Hygiene and Sanitation in Aviation of 2009 2009
Public Health Act, 2009 2009
International Health Regulation ,2005 2005
National Waste and Human Remains Policy Guidelines 2011
National Plan for Building Climate Change Adaptation in Health through resilient 2014 - 2017
water, sanitation and hygiene

Social Welfare
Title of document Period
The National ageing policy 2003
National Disability Policy 2004
The child development policy 2008
The persons with disability Act 2010
WHO Wheel chair Guideline 2009

91
Title of document Period
The Law of the child Act 2009
Anti-Trafficking in persons Act 2008
Health Sector Strategic Plan III 2010-2015
National Costed Plan of Action for most vulnerable children –II 2013-2017
Sexual offences (with Special Provision Act) 1998
The Destitute Ordinance 1923
The Law of marriage Act No: 5 1971
Multi-sectorial Action plan on violence Against children 2013-2016
The Social welfare Policy
The multi-Sector National Plan of Action to Prevent and Respond to violence Against July 2013 – June
Children 2016
Violence Against Children in Tanzania; Findings from a National Survey 2009 2011
Five year Strategy for Progressive Child Justice Reform 2013 – 2017, (report’) 2014
Mpango Mkakati wa miaka mitano wa haki za watoto 2013 – 2017 2013
Disability Mainstreaming Strategic plan 2010-2015 2010
Department of Social Welfare Strategic Plan 2007 – 2011 2007
National Human Rights Action Plan 2013-2017 2013

Support Systems
Human Resources for Health
Title of document Period
Human Resource for Health and Social Welfare Policy Guideline 2014-2019
Human Resource for Health and Social Welfare Strategic Plan 2014-2019
Human Resource for Health and Social Welfare Production Plan 2014-2019
Human Resource for Health and Social Welfare Staffing Levels Guideline 2014-2019
Human Resource for Health and Social Welfare Country Profile 2014
Human Resource for Health and Social Welfare Information System and Training 2013
Institutions Information System Data Utilisation Guideline

Pharmaceuticals and Supplies

Title of document Period
National Medicines Policy (NMP) 2013 n/a
NMP Implementation Strategy 2014 2014-2024
(Addendum to NMP, above)
National Pharmaceutical Sector Action Plan 2020 2014-2020
(PSAP 2020)
PSAP 2020 Costed Implementation Plan 2014-2017
(Initial 3-year rolling plan, addendum to PSAP 2020, above)
MSD Medium-Term Strategic Plan (MTSP) 2014-2020
TFDA Strategic Plan 2012/13 to
2016/17
Pharmacy Council Strategic Plan 2013-2018
Tanzania Pharmaceutical Manufacturing Plan of Action 2014-2018
SADC Pharmaceutical Business Plan 2015 -2019

Monitoring and Evaluation

Title of document Period
M&E Strengthening – 5 Year Strategy – A Tanzanian Platform for Health Information 2015 – 2020
and Accountability
M&E Strengthening Initiative – Annual Work plans, Budgets and Reports 2010 to 2015
Global Fund Round 9 M&E Strengthening Phase 2 2014 - 2016
HSSP IV – M&E Plan 2015 – 2020

92
Title of document Period
TACAIDS M&E Strategy
Tanzania Third National Multi-Sectoral Strategic Framework For HIV AIDS (2013/14 –
2017/18); Nov 2013. Section 6 Monitoring, Evaluation and Research
NACP M&E Strategy
NACP Third Health Sector HIV and AIDS Strategic Plan (HSHSP - III) 2013-2017, section
9, M&E plan, page 69
NMCP M&E Strategy
RCHS M&E Strategy and Sharpened One Plan
The National Road Map Strategic Plan To Accelerate Reduction of Maternal, Newborn
and Child Deaths in Tanzania; Section 6 Monitoring Framework, page 47
TB/L M&E Strategy The NTLP Strategic Plan 2009/2010 - 2015/2016. M&E, section
11, page 48
PMORALG M&E Strategy
PMORALG Strategic Plan 2011/12 - 2015/2016 Performance Indicators are listed on
page 26.
DSW M&E Strategy
WASH M&E Strategy
Water Aid Tanzania strategy, 2011-2016 includes objectives, and M&E discussion.
NATIONAL STRATEGIC PLAN FOR SCHOOL WATER, SANITATION AND HYGIENE
(SWASH) 2012 -2017 (Under MOE), M&E in Section 5, page 38
Multi-sectoral; Under MKUKUTA, National Water Sector Development Strategy
(NWSDS) 2006 - 2015, section 7 focused on performance M&E, page 68
Draft Data Use and Dissemination Strategy
The Tanzania national DDU strategy 2015 - 2020, includes M&E as a core strategic
objective, and a logic model that links activities to outputs, outcomes and impact.
M&E framework, Section 5, page 15
e-Health Strategy
The Tanzania e-Health Strategy, 2013 - 2018. The e-Health strategy M&E framework,
section 5, page 14
NIMR Strategy
NIMR Strategic Plan IV, 2014-2019 Part 2, the M&E framework, page 18.
Community Based Data Management systems Guidelines
PPP Strategy and M&E Plan
National Nutrition Strategy and M&E Plan
List of 100 Core Health Indicators October 2014
Monitoring, Evaluation and Review of national health Strategies - A Country-Led November 2011
Platform for Information and Accountability
Improving Data Use in Decision making- An Intervention to Strengthen Health August 2012
Systems

Governance and Financing

Public Private Partnership
Title of document Period
National Public Private Partnership 2009 2009
PPP Act 2010 2010
PPP Regulations 2011 2011
PPP Amendment Bill 2014 2014
MOHSW PPP Policy Guidelines 2012
MOHSW PPP Strategic Plan 2010-15
MOHSW PPP Strategic Plan Review 2014
PPP TWG Plan of Action 2014-15

93
Health Care Financing
Title of document Period
Cost-sharing policy guidelines Dec 1997
CHF Act of 2001 To date
NHIF Act of 1999 To date
MOU between MOHSW, PMO-RALG and NHIF 2012 - 2015
RBF design document 2015 -
Health Basket Fund MOU 2009 –2015
Health Financing Strategy (HFS) 2015 –2025
NHIF Strategic Plan 2010 - 2015

94
Annex 2 Detailed cost results, targets and fiscal space
assumptions

Cost and Targets

Commodity costs (TZS billions) by program

Program 2015/201 2016/201 2017/201 2018/201 2019/202 Total
6 7 8 9 0
HIV/AIDS 415 453 466 490 518 2,342
NCDs 299 372 453 538 627 2,290
Oral care 132 144 156 170 186 786
General services 130 132 135 137 139 672
Malaria 183 123 121 119 118 665
Immunization & vaccine 127 120 116 105 97 564
Maternal, newborn, and
reproductive health 65 76 86 94 102 425
Child & adolescent
health 25 46 70 86 98 325
Orthopedic/Trauma 39 40 41 41 42 202
Mental health 25 28 30 31 31 144
TB and leprosy 16 19 21 23 26 106
NTDs 21 17 13 13 13 76
Ophthalmology 3 3 3 2 2 12
Nutrition* 2 2 2 2 2 10
Environmental Health 0.1 0.1 0.1 0.1 0.1 0.3
Total 1,480 1,574 1,711 1,852 2,001 8,619
Note: Not all programs procure commodities (ex: health promotion).
*Excludes nutrition costs under maternal and child health.

Cross-cutting nutrition commodity costs (TZS billions)

Type of cost 2015/2016 2016/2017 2017/2018 2018/2019 2019/2020 Total
Maternal health 0.8 2 3 4 5 13
Child health 10 26 47 60 70 212
Other 2 2 2 2 2 10
Total 13 30 52 66 77 235
Includes cost of vitamin and micronutrient supplementation, food fortification, treatment of MAM and
SAM, treatment of anaemia, and nutrition supplementation for people living with HIV

Key coverage targets used in commodity costing by program

Highest cost intervention 2015/2016 2019/2020
Program within each program coverage* coverage*
HIV/AIDS Antiretroviral therapy (ART) 64% of PLHIV 90% of PLHIV
NCDs Treatment of type I diabetes 20% 100%
Immunization &
Pneumococcal vaccine 95% 95%
vaccine
Oral care Oral cancer treatment 21% 21%
General services Hearing loss 3% 3%
Campaign
8,000,000 LLINs
Malaria Insecticide treated materials distribution of
distributed per year
18,765,840 LLINs

95
 Highest cost intervention 2015/2016 2019/2020
Program within each program coverage* coverage*
Maternal, newborn,
Labour and delivery
and reproductive 50% 80%
management
health
Child & adolescent Management of severe acute
2% 10%
health malnutrition
Orthopedic/Trauma Internal fixation 32% 32%
70% of all TB & MDR 70% of all TB & MDR
TB and leprosy Smear tests for TB
cases cases
Identification and assessment of
Mental health 10% 10%
new cases of drug use
Lymphatic filariasis control and 80% of those in 80% of those in
NTDs
treatment endemic areas endemic areas
Treatment for infectious
Ophthalmology 50% 50%
diseases of the eye
Nutrition Salt iodization 8,000 kg per year 8,000 kg per year
*Coverage is defined as the percentage of people in need of an intervention who are reached.

Program management costs by program(TZS billions)

Program 2015/201 2016/201 2017/201 2018/201 2019/202 Total
6 7 8 9 0
HIV 188 145 129 140 126 728
TB and leprosy 76 103 91 89 93 451
Maternal, newborn, and
74 76 72 77 67 365
reproductive health
Malaria 77 64 65 66 67 339
Child & adolescent health 57 57 45 45 28 232
Environmental health 50 43 49 43 43 229
Department of Social
14 15 17 21 23 90
Welfare
NCDs and mental health 16 15 16 16 16 79
NTDs 7 7 7 7 7 34
Health promotion 4 4 4 2 2 16
Nutrition 2 3 3 3 4 15
Oral care 2 2 2 2 2 12
Ophthalmology 3 2 1 1 1 8
Orthopedic/trauma 2 1 1 1 1 7
Alternative and
1 0.4 0.4 0.3 0.3 2
traditional medicine
Total 573 538 503 514 480 2,608
Note: Not all programs have separate program management costs (ex: general services).

Detailed HRH costs (TZS billions) and targets (personnel)

2015/201 2016/201 2017/201 2018/201 2019/202 Total
6 7 8 9 0
HRH costs
Salaries 607 664 726 788 858 3,643
Benefits 109 119 130 141 154 653
Human resource
24 24 25 19 23 115
administration*
Total 740 807 881 948 1,034 4,411
HRH targets in numbers of personnel
No. of service providers 70,883 76,049 81,731 87,417 94,141
Nurses 16,882 17,952 19,021 20,091 21,160
Formalized CHWs 320 840 1,880 2,920 5,000

96
No. of support staff 8,946 10,332 11,719 13,105 14,494
Total no. of HRH 79,829 86,381 93,450 100,522 108,635
*Includes costs for training, retention incentives, HRHIS maintenance, etc.

Detailed Logistics costs (TZS billions)

Type of cost 2015/201 2016/201 2017/201 2018/201 2019/202 Total

6 7 8 9 0
Commodity freight,
clearance, and quality
assurance costs 192 205 222 241 260 1,120
Commodity wastage
costs 144 1547 168 182 197 845
Warehouse construction
and operating costs 13 18 13 11 16 71
Vehicle purchase,
maintenance, and fuel
costs 20 25 22 29 30 126
Warehouse worker
wages costs 4 4 4 4 4 21
Third party logistics
contracts 1 2 2 2 2 8
BRN costs related to
commodity management 10 5 7 0 0 22
Total logistics costs 388 414 440 469 509 2,219

Detailed Infrastructure costs (TZS billions)

Type of cost 2015/201 2016/201 2017/201 2018/201 2019/202 Total
6 7 8 9 0
New construction costs 54 87 44 34 35 254
Rehabilitation costs 90 90 83 76 76 414
Equipment and furniture
4 31 29 27 27 119
costs
Facility operating costs 227 229 232 234 237 1,158
Vehicle purchase costs 66 43 45 45 45 244
Vehicle operating costs^ 125 126 128 129 130 638
Infrastructure program
24 4 14 3 14 59
management*
Total 590 610 574 548 565 2,887
^Includes cost of fuel, drivers, and maintenance
*Includes costs related to infrastructure under BRN

Detailed Infrastructure targets (number of facilities)

Number to be Small-scale Equipment maintenance
Facility type constructed rehabilitation (No.) and replacement (No.)
Dispensaries 790 3,057 2,205
Health centers 35 242 160
District hospitals 9 60 42
Regional referral hospitals 0 7 5
National, special, zonal hospitals 0 3 2
Total 834 3,369 2,414

97
Fiscal space
Generally, there are no publicly available future commitment values from development partners.
Data are entered into the aid management portal (http://amp.mof.go.tz/) when available.
However, these data were not made available for this fiscal space exercise and hence figures
were sourced where possible directly from DPs or appropriate assumptions were made in
concert with MOHSW. All values were converted into constant FY 2014 Tanzanian shillings using
appropriate deflators prior to comparison with HSSP IV costs. However, all tables below display
current Tanzanian shillings.

On-budget, non-basket funding sources, current TZS billions

Sources 2013/14 2014/15 2015/1 2016/1 2017/1 2018/1 2019/2 2020/2
6 7 8 9 0 1
Global Fund 346 207 450 588 558 530 504 479
UNICEF 12 11 11 11 11 11 11 11
World Bank 28 17 17 53 104 104 104 111
UNDP 15 18 18 18 18 18 18 18
Others 49 12 12 12 12 12 12 12
Total 450 266 509 682 703 676 649 631
Notes: Where possible, data were sourced from recent commitments or from values provided by
DPs. World Bank values are mixed, comprising grant (GFF related trust fund monies) and IDA
concessional loan. For the Global Fund, values after 2017/18 are assumed, based on 5% decline
p.a.

External resources off-budget, current TZS billions

Sources 2013/14 2014/15 2015/1 2016/1 2017/1 2018/1 2019/2 2020/2
6 7 8 9 0 1
USAID 602 602 602 594 564 536 509 484
GIZ 10 10 10 10 10 10 10 10
DANIDA 56 56 56 56 56 56 56 56
CDC 62 62 62 62 59 56 54 51
DFID 41 43 55 38 34 6 6 6
SDC 7 7 7 7 7 7 7 7
DOD 71 71 71 71 67 64 60 57
Canada 119 119 119 119 95 76 61 49
IrishAid - 4 6 6 6 6 6 6
UN Agencies 20 20 20 20 20 20 20 20
Total 988 994 1,008 983 918 837 789 746
Notes: Where possible, data were sourced from recent commitments or from values provided by
DPs. Values were kept constant due to a lack of data for GIZ, SDC, and UN Agencies. For Canada,
some of the planned resources are included in the GFF trust fund managed by the World Bank.
The remaining bilateral funds from Canada were assumed to decline 20% p.a. from 2017/18.
USAID resources were assumed to decline 5% p.a. from 2017/18.

Innovative financing sources (other than SNHI), current TZS billions

Sources 2015/1 2016/1 2017/1 2018/1 2019/2 2020/2
6 7 8 9 0 1
Allocation from the surplus of
- 129 138 146 156 166
public corporations
Airtime taxes - 100 106 113 120 128
Alcohol and tobacco taxes - 260 276 294 313 333
AIDS Trust Fund (GOT and non-
3 100 300 300 300 300
GOT contrib.)
Total 3 589 820 853 889 926

98
Notes: These values are based on detailed analysis of actual tax or revenue collections for all but
the AIDS Trust Fund. Proportional allocations from these sources to the health sector were based
on discussions with MOHSW and feedback from stakeholders. MOF stakeholders were also
present in these discussions. For the 20% allocation from the surplus of public corporations to
health, analysis of FY 2013/14 values suggests that vs. the estimated nominal GDP for that year, a
level of 0.126% of GDP is appropriate going forward, which assumes that revenues will rise
proportionately with GDP. Similarly, for the 17% allocation from mobile communication/airtime
taxes to health, a value of 0.097% of GDP per year was estimated; and the same value for the 33%
allocation from alcohol and tobacco taxes was 0.253% of GDP. The AIDS Trust Fund values are
based on discussion with TACAIDS and are speculative.

Government of Tanzania and the Health Basket Fund, current TZS billions
Sources 2013/1 2014/1 2015/1 2016/1 2017/1 2018/1 2019/2 2020/2
4 5 6 7 8 9 0 1
GOT domestic
804 1,031 1,052 1,073 1,094 1,116 1,138 1,161
resources for health
Health Basket Fund 135 109 47 45 42 40 38 36
Notes: GOT sources are an aggregation of allocation to recurrent and development spending
across MOHSW, PMO-RALG, regions, and LGAs. This included LGA own source revenues, which
were estimated based on recent actuals and an increasing allocation to health was projected.
Overall, for non-LGA sources, an increase of 2% p.a. was estimated from FY 2015/16. For the
Health Basket Fund, values up to 2014/15 were based on available data, and from FY 2015/16, in
the absence of details for the renewed commitment; an assumption was based on a 5% projected
annual decline per year.

99
 Annex 3 Health Sector Performance Indicators

2015 2020 Data

Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Health Status
Mortality
Neonatal The number of Number of Number of live 26 16 TDHS TDHS, census Impact res BRN SDG
mortality rate newborn deaths newborns births per 1000 in (TDHS 2010; Census intervals sex RMNCAH GRL10
that occur within who die a given period 2006-2010) wea 0
the first 28 days of within the edu
life per 1000 live first 28 days
births in a given of life
period.
Infant mortality The number of Number of Number of live 45 35 TDHS TDHS, census Impact res MDG
rate infants who die infant deaths births per 1000 in (Census 2012) Census intervals sex GRL10
within the first year within the a given period SPD SAVVY wea 0
of life per 1000 live first year of SAVVY (annual) edu
births in a given life.
period.
Under-five The number of Number of Number of live 81 55 TDHS TDHS, census Impact res RMNCAH MDG
mortality rate children who die child deaths births per 1000 in (TDHS 2010; Census intervals sex SDG
within the first five within the a given period 2006-2010) SAVVY SAVVY wea GRL10
years of life per first five (annual) edu 0
1000 live births in a years of life.
given period.
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Maternal The number of Number of Number of live 432 292 TDHS TDHS, census Impact res BRN MDG
mortality ratio women who die of women who births x 100,000 (Census 2012) Census interval wea RMNCAH SDG
causes related to die of causes SAVVY (CoD) SAVVY edu GRL10
pregnancy, related to (annual) 0
delivery, and post- pregnancy,
partum per 100 delivery, or
000 live births in a post-partum
given year or other
period.
Causes of maternal
death: any cause
related to or
aggravated by
pregnancy or its
management
(excluding
accidental or
incidental causes)
during pregnancy
and childbirth or
within 42 days of
termination of
pregnancy,
irrespective of the
duration and site of
the pregnancy.
Life expectancy at The average number of years that a newborn could 61 Trend Census census Impact res Vision SDG
birth expect to live, if he or she were to pass through life F: 63 y Survey interval sex 2025 GRL10
exposed to the sex- and age-specific death rates M: 60 y wea 0
prevailing at the time of his or her birth, for a specific (Census 2012) edu
year, in a given country, territory, or geographic area.
Calculated from life tables.

101
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Fertility
Total fertility rate The average Sum of age None 5.2 Trend TDHS TDHS interval Impact res GRL10
number of children specific (Census 2012) census census wea 0
a hypothetical fertility rates SAVVY interval edu
cohort of women for age SAVVY
would have at the groups (annual)
end of their comprising
reproductive 15-49 age
period if they were group.
subject during their
whole lives to the
fertility rates of a
given period and if
they were not
subject to
mortality.It is
expressed as
children per
woman.

102
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Service delivery
Reproductive
Health
Contraceptive Survey: Percentage Number of Survey: Number of All methods: All HMIS HMIS Outcome res BRN SDG
prevalence rate of women aged 15- women 15- women between 36% methods:60 TDHS Annual wea RBF GRL10
(modern 49 years who are 49 years of 15 and 49 years of Modern % TDHS interval method RMNCAH 0
methods) currently using, or age who are age in survey. methods: 27% Modern edu
whose sexual currently HMIS: Number of (TDHS 2010) methods: star
partner is using, at using a women between 48% 45% brn
least one modern modern 15 and 49 years of (HMIS 2014) (TDHS) rbf
method of contraceptiv age in catchment 60%
contraception, e method x area (HMIS)
regardless of the 100
method used.
HMIS: The
percentage of
women aged 15-49
years, regardless of
marital status, who
have received at
least one modern
method of
contraception from
a health facility
during the year,
regardless of the
method used.

103
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Adolescent Annual number of Annual Total number of 116 80 per 1000 TDHS TDHS interval Outcome res RMNCAH MDG
fertility rate births to women number of women in the age (TDHS 2010) women Population census wea SDG
aged below 20 births to group below 20 Census interval edu GRL10
Adolescence years per 1 000 women aged years per 1 000 SAVVY SAVVY 0
fertility (pregnant women in that age below 20 (annual)
before 20 years group. years
old)

Antenatal care Percentage of Number of Estimated number 15% 40% HMIS HMIS Outcome res BRN
coverage: first pregnant women pregnant of pregnant (< 4 months (< 4 months TDHS (Monthly) wea RBF
visit before 12 who start ANC women who women. TDHS 2010) TDHS) (< 4 months) TDHS interval edu RMNCAH
weeks gestational before 12 weeks of start ANC 15% 40% star
age gestational age before 12 (HMIS 2014) (HMIS) brn
weeks of rbf
gestational
age x 100
Antenatal care Percentage of Number of Estimated number 43% 60% HMIS HMIS Outcome res BRN MDG
coverage: 4 visits pregnant women pregnant of pregnant (TDHS 2010) (TDHS) TDHS (Monthly) wea RBF GRL10
who attended women who women. 40% 60% TDHS interval edu RMNCAH 0
antenatal care four received (HMIS 2014) (HMIS) star
or more times in a antenatal brn
given time period. care four or rbf
more times x
100

104
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Institutional Percentage of Number of Estimated number 50% 65% HMIS HMIS Outcome res PAF GRL10
delivery coverage women who who of deliveries (TDHS 2010) (TDHS) TDHS (Monthly) wea BRN 0
PAF: delivered in a delivered in a 54.7% 65% TDHS interval edu RBF
Percentage of health facility health facility (HMIS 2014) (HMIS) star RMNCAH
councils in during a specified x 100 brn
which at least time period rbf
60% of
deliveries take
place in health
facilities
Percentage Percentage Number of Estimated number 51% 60% TDHS TDHS interval Outcome nat MDG
deliveries deliveries assisted deliveries of deliveries (TDHS 2010) GRL10
assisted by skilled by skilled health assisted by 0
health attendants attendants skilled health
(doctors, clinical attendants x
officers, nurses, 100
nurse midwives)
Postnatal care: Percentages of Number of I: Estimated I: 56% I: 68% HMIS HMIS Outcome res BRN
within 7 days mothers and of mothers and number of live M: 57% M: 70% TDHS (Monthly) wea RBF
after delivery infants who number of births (HMIS 2014) (HMIS 2014) TDHS interval edu RMNCAH
received postnatal infants who M: Estimated star
care within seven received number of brn
days of childbirth postnatal deliveries rbf
(regardless of place care within
of delivery) seven days of
childbirth x
100

105
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
BEmONC at Percentage of 1) Number of 1) Total number of 1) 1) 20% 1) 70% special study study interval Input res BRN
dispensaries and dispensaries and 2) dispensaries dispensaries and 2) 39% 2) 70% star RMNCAH
health centers health centres that and 2) health 2) health centres. (SARA 2012) brn
provide centres that rbf
BEmONCseven provide
signal functions as BEmONC as
defined in EHP. defined in
EHP
CEmONC at Percentage of 1) Number of 1) Total number of 1) 1) 9% 1) 50% special study study interval Input res BRN
health centers health centres and health health centres and 2) 73% 2) 100% star RMNCAH
and hospitals 2) hospitals that centres and 2) hospitals. (SARA 2012) brn
provide CEmONC 2) hospitals rbf
nine signal that provide
functions as CEmONC as
defined in EHP. defined in
EHP
Vaccinations
Vaccination rate: Proportion of Total Total number of 75% 90% HMIS HMIS Outcome res RBF MDG
measles under children under one number of children under one (TDHS 2010) (TDHS) TDHS (Monthly) sex RMNCAH GRL10
one year received measles children year targeted in 90.51% 90% TDHS interval wea 0
vaccine in a given under one the period (HMIS 2014) (HMIS) edu
year or other year star
period. vaccinated brn
against rbf
measles x
100

106
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Vaccination rate: Proportion of Total Total number of 86% 90% HMIS HMIS Outcome res RMNCAH GRL10
Penta3 under one children under one number of children under one (TDHS 2010) (TDHS) TDHS (Monthly) sex 0
year received Penta3 children year targeted in 82.07% 90% TDHS interval wea
vaccine in a given under one the period (HMIS 2014) (HMIS) edu
year or other year star
period. vaccinated 3 brn
times against rbf
DPT - Hb x
100
Vitamin A Survey: Proportion Survey: Total Survey: Total 61% 75% HMIS HMIS Outcome res RBF GRL10
supplementation of children 6–59 number of number of children (TDHS 2010) (TDHS) TDHS (Monthly) sex RMNCAH 0
coverage months who children aged aged 6–59 months 51% 65% TDHS interval wea
received 1 dose of 6–59 months in the sample. (HMIS 2014) (HMIS) edu
vitamin A in the who received HMIS: Number of star
past 6 months. 1 dose of children 12–59 brn
HMIS: Ratio of vitamin A in months rbf
Vitamin A doses the past 6
given to children months x 100
12–59 months in HMIS:
past 12 months to Number of
number of children Vitamin A
12–59 months. doses given
to children
12–59
months in
past 12
months

107
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Nutrition
Children under 5 Proportion of Number of Number of 16% 11% TDHS TDHS interval Impact res Nut TWG MDG
who are under-fives who children who children under five (TDHS 2010) (TDHS) wea
underweight are underweight are years of age edu
(weight for age) underweight
(weight-for-
age less than
-2 standard
deviations of
the WHO
Child Growth
Standards
median)
among
children aged
0-4 years x
100
Children under 5 Proportion of Number of Number of 42% 27% TDHS HMIS Impact res Nut TWG GRL10
who are stunted under-fives who children who children under five (TDHS 2010) (TDHS) (Monthly) wea 0
are stunted (height are stunted years of age TDHS interval edu
for age) (height-for-
age less than
-2 standard
deviations of
the WHO
Child Growth
Standards
median)
among
children aged
0-4 years x
100

108
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Incidence of low Percentage of live Number of Number of live 7.3% <2% HMIS HMIS Output res Nut TWG GRL10
birth-weight births that weigh live births births (HMIS 2014) (TDHIS & TDHS (Monthly) wea RMNCAH 0
among newborns less than 2500 g that weigh 6.9% HMIS) TDHS interval edu
out of the total of less than (TDHS 2010) star
live births during 2500 g x 100 brn
the same time rbf
period.
Percentage of Percentage of Number of Number of women 59% 35% HMIS (to be Monthly Impact res Nut TWG GRL
pregnant women women (15-49 cases of aged between 15 - (TDHS 2010) (TDHS&HMIS added) weaedu 100
with anaemia years) who have women who 49 years who have ) TDHS
haemoglobin are Anemic haemoglobin THMIS
concentration <11 concentration<11
g/dl) g/dl
HIV/AIDS
HIV prevalence in Percentage of Number of Total population 15-19: 1.0%; 15-19: 0.8%; THMIS THMIS Impact age NACP SP MDGG
15-24 year age young people aged people aged [tested] in the age 20-24: 3.2% 20-24: 2.4% interval RL100
group 15–24 years who 15 –24 years group 15 – 24 (THMIS 2012) by
are living with HIV who were years 2017(NACP)
tested to be
HIV positive
x 100

109
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
ARV Coverage Number and Number of Estimated number Adults: 60%; Adults: 95%; model + RHIS Annual Outcome Sex, Age: NACP SP MDG
percentage of adults and of eligible adults Children: 25% Children: <1 1-4 5-14 SDG
eligible adults and children and children in 2012 80% 15+ GRL10
children currently eligible for (NACP) by 2017 0
receiving ART (NACP)
antiretroviral receiving
therapy ART
(disaggregat
ed under 5
and over 5
and sex) x
100
Prevention of Percentage of HIV- Number of Number of HIV- 65% 90% model + RHIS Annual Outcome New to NACP SP MDG
Mother-to-Child infected pregnant HIV-infected infected pregnant in 2012 in 2017 ART, RBF GRL10
Transmission women receiving pregnant women (NACP) (NACP) Already on RMNCAH 0
ARVs to reduce the women ART
risk of PMTCT receiving
ARVs for
PMTCT x 100

110
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Malaria
Intermittent Survey: Proportion Survey: Survey: Number of 33% 80% TDHS TMIS & TDHS Output res RBF GRL10
preventive of mothers who Number of mothers surveyed (THMIS 2012) (THMIS) TMIS and intervals wea NMCP 0 (3
therapy for received two doses mothers who had a live 34% 80% other HMIS edu RMNACH doses)
malaria during of preventive receiving 2 birth in past 2 (HMIS 2014) (HMIS) household (Monthly) star
pregnancy (IPTp) intermittent or more years surveys brn
treatment for doses SP HMIS: Total HMIS rbf
malaria during last during last number of first
pregnancy. pregnancy ANC visits
HMIS: Proportion of within past 2
mothers who yrs
received two doses HMIS:
of preventive Number of
intermittent mothers
treatment for receiving 2
malaria during or more
pregnancy during a doses SP
specified time during
period. pregnancy
Use of long lasting Proportion of Number of Number of <5 yrs: 72% <5 yrs: 80% TDHS TMIS & TDHS Outcome res NMCP MDG
insecticide vulnerable groups children <5 children <5 or PW: 75% PW: 80% TMIS and intervals edu GRL10
treated nets (pregnant women or pregnant pregnant women (THMIS 2012) other wea 0
(LLIN) 15-49 yrs of age, women 15- 15-49 yrs who household
children under 5) 49 years reside in surveyed surveys
sleeping under an sleeping households
LLIN the previous under ITN
night night before
survey

111
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Children with Proportion of Number of Number of 25% 80% TDHS TMIS & TDHS Outcome res NMCP
blood test in children under 5 children children under 5 (THMIS 2012) (HMIS) TMIS and intervals edu
febrile illness (2-59 months) who under 5 (2- (2-59 months) who other wea
had a blood test 59 months) had a febrile illness household
taken in febrile who had a in last 2 weeks surveys
illness in last 2 blood test
weeks taken in
febrile illness
in last 2
weeks x 100
Confirmed Proportion of Number of Total number of 64% 95% HMIS Monthly Outcome res
malaria cases confirmed malaria confirmed malaria cases (HMIS 2014) (NMCP) <5
cases out of total malaria cases (clinical + >5
malaria cases x 100 confirmed)
(clinical +
confirmed)
Malaria parasite Percentage of Number of Number of 4.1% <1% TMIS and TMIS Impact res NMCP GRL10
prevalence children aged 6–59 children children tested by (THMIS 2012) (NMCP) other intervals edu 0
among children 6- months who test positive by microscopy x 100 household wea
59 months positive for malaria microscopy x surveys
by microscopy 100

112
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Tuberculosis and Leprosy
Case detection The proportion of The number WHO's estimate of 56% 72% NTLP Annual Outcome res NTLP GRL10
rate for all forms estimated new and of new and the number of in 2013 HMIS star 0
of tuberculosis relapse relapse TB incident TB cases (NTLP) WHO brn
tuberculosis (TB) cases for the given year. rbf
The term "rate" is cases detected in a diagnosed Available online at
used for historical given year under and treated www.who.int/tb/d
reasons; the the internationally in national ata
indicator is recommended TB control
actually a ratio tuberculosis programmes
(expressed as control strategy. and notified
percentage) and to WHO x
not a rate. The term “case 100 (TB
detection”, as used notification
here, means that TB rate)
is diagnosed in a
patient and is
reported within the
national
surveillance
system, and then to
WHO.

113
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Treatment Proportion of all TB Number of Number of 90% >90% NTLP Quarterly Outcome res NTLP GLR10
success rate for cases, all forms, TB patients tuberculosis cases in 2013 HMIS star 0
all forms of bacteriologically who registered for (NTLP) brn
tuberculosis confirmed plus successfully treatment rbf
clinically completed
diagnosed, treatment x
successfully treated 100
among all TB cases
registered for
treatment during
the specified
period.
Disability grade at Proportion of Number of Number of newly 13% 7% NTLP Quarterly Impact res NTLP
leprosy diagnosis patients with patients with diagnosed leprosy in 2013 HMIS star
disability grade 2 disability cases (NTLP) brn
among newly grade 2 at rbf
diagnosed leprosy diagnosis x
patients 100
Children among Proportion of Number of Number of newly 5% <2% NTLP Annual Impact res NTLP
newly detected patients under age patients diagnosed leprosy in 2013 HMIS star
cases 15 years among under age 15 cases (NTLP) brn
newly diagnosed years x 100 rbf
leprosy patients

114
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Infectious and non-communicable
diseases
Obesity and Percentage of Number of Adult (24-65 o'weight: no increase in STEPS STEPS Impact sex NCD SDGGR
overweight adults 25-64 years adults 25-64 years) population 26.0% obesity interval L100
among adults who are overweight years who surveyed. M: 15.1% (NCD AP)*
(defined as having a are F:37.1%
BMI ≥25 overweight Obese8.7%
kg/m²)Percentage (defined as M: 2.5%
of adults 25-64 having a BMI F: 15.0%
years who are ≥25 kg/m²) x (STEPS 2012)
obese (defined as 100Number
having a BMI ≥ 30 of adults 25-
kg/m²) 64 years who
are obese
(defined as
having a BMI
≥ 30 kg/m²)
x 100
Raised blood Percentage of Number of Adult (24-65 26.0% reduced by STEPS STEPS Impact sex NCD SDG
pressure among adults 25-64 years adults (24-65 years) population M: 25.4% 25% interval GRL10
adults with BP > 140/90 years) with surveyed. F: 26.5% 19.5% 0
or are currently on BP > 140/90 (STEPS 2012) M: 19.1%
BP medication or are F: 19.9%
currently on (NCD AP)*
BP
medication x
100

115
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Raised glucose / Percentage of Number of Adult (24-65 9.1% reduced by STEPS STEPS Impact sex NCD SDG
diabetes among adults 25-64 years adults (24-65 years) population M:8.0% 10% interval GRL10
adults with raised fasting years) with surveyed. F: 10.0% 8.2% 0
blood glucose with raised (STEPS 2012) M: 7.2%
(capillary whole fasting blood F: 9.0%
blood value 6.1 glucose (NCD AP)*
mmol/L (110 (capillary
mg/dl)) or are whole blood
currently on value 6.1
medication for mmol/L (110
raised blood mg/dl)) or
glucose are currently
on
medication
for raised
blood
glucose x 100
Cervical cancer Proportion of Total Number of women 11% Tbd HMIS Monthly Output res SDG
screening women aged 30-50 number of aged 30–50 years (HMIS 2014) star GRL10
who were screened women brn 0
for cervical cancer between 30 rbf
with Visual and 50 who
Inspection with were
Acetic Acid/vinegar screened
(VIA). with Visual
Inspection
with Acetic
Acid/vinegar
(VIA) x 100

116
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Social Welfare
Direct Services
Children in need Proportion of Number of Number of 27.6% 50% HMIS (to be Annual Outcome res
of care and vulnerable children eligible children in need of (Census 2012) added) Gender MVC;
protection who and children in children who care, protection and Children VANE;
received services. need of care and received and support Desk Register; Juvenile
protection services as services reported Police Register Offenders;
provided with determined to the social disability
appropriate by the welfare offices or
services from the assessed other local
social welfare office needs x 100 government
in collaboration authorities
with other key
service providers.
Disaggregated by
type of service:
Most Vulnerable
Children (MVC);
Victims of Violence,
Abuse, Neglect and
Exploitation
(VANE); Juvenile
Offenders;
disability).

117
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Adults in need of Proportion of Number of Number of eligible Elderly: 5.6% Elderly: 50% HMIS (to be Annual Outcome res
welfare and adults who are eligible adults (elderly, Disabled: Disabled: added); Elderly
protection who elderly, disabled, adults disabled and 5.8% 50% Police Register Poor
received services. with matrimonial (elderly, extremely poor) (Census 2012) Disability
cases or living in disabled or who sought
poor households extremely services reported
who received poor) who to the social
appropriate received welfare offices or
services from the services as other local
social welfare determined government
office, other local by the authorities (health
government assessed facilities/One Stop
authorities or non- needs X 100 Centres, schools)
state actors. and Police
Disaggregated by
type of service.

118
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Capacity
LGAs with Proportion of LGAs Total Total number of 70% have 100% of all HMIS Outcome Annual DCPTs
improved with improved number of LGAs MVCCs the districts CPMIS MVCCs;
capacity to coordination of LGAs that without have Programmes adult
provide quality prevention and have increased improved services
welfare and response services coordinated resources; capacity
protection to children and mechanisms 18% have coordination
services adults in need of for the DCPTs with the services
welfare and provision of increased
protection services. preventive resources
LGAs will be and response
considered to have services.
improved capacity
if observe staffing,
training and
budgeting norms.
Disaggregated by
Most Vulnerable
Children
Committees
(MVCC), District
Child Protection
Teams (DCPT) and
adult services X
100

119
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Health facilities Proportion of Number of Total number of 0% 30% in RITA tbd Output res
providing birth health facilities that health health facilities in (RITA) regions HDSS star
registration and are implementing facilities regions where rolling out brn
birth certification the new consistently RITA has the new rbf
services decentralized registering decentralized the system registratio
system for births and new birth n;
registration of issuing birth registration certificatio
births and issuance certificates x services n
of birth certificates. 100
X 100
Health Systems
Financial
Share of total Proportion of total on- Total on-budget 9.1% 10.0% MOF data in Annual Input HFS
Government government budget Government (PER 2014) PER
expenditure expenditures health budget
allocated to allocated to health budget(MOF
Health in total government definition)
expenditures (excl.
CFS) x 100
Enrollment in Proportion of Population Total population 19% 50% PER Annual Output res HFS UHC
social health population enrolled enrolled in (NHIF data (others for
Insurance in any of the any of the 2013) survey
schemes following schemes - following data)
NHIF, NSSF-SHIB, schemes -
CHF, TIKA, CHIF, NHIF, NSSF-
and others SHIB, CHF,
TIKA, CHIF,
and others
Human
Resources

120
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Medical Officers Number of Medical Number of Total population ÷
and AMO per 10 Officers / Assistant Med. 10 000 in the
000 population Medical Officers Specialists whole country
per 10,000 MOs / AMOs
population in the in the whole
whole country country
Clinicians per 10 Number of Medical Number of Total population ÷ 2.21 HRHIS Annual Input Region
000 people in the Officers / Assistant Med. 10 000 in the 9 council
9 BRN Regions Medical Officers Specialists BRN Regions
and COs / ACOs MOs / AMOs
per 10,000 and COs /
population in the 9 ACOs in the 9
BRN Regions BRN Regions
Clinicians per 10 Number of Medical Number of Total population ÷ HRHIS Annual Input Region
000 people in the Officers / Assistant Med. 10 000 in the council
whole country Medical Officers Specialists whole country
and COs / ACOs MOs / AMOs
per 10,000 and COs /
population in the ACOs in the
whole country whole
country
Nurses and Number of Nurses Number of Total population ÷ 4.21 7.50 HRHIS Annual Input Region
midwives per 10 and Midwives per Nurses and 10 000 in the 9 council
000 people at the 10,000 population Midwives BRN Regions
primary care level at the primary care available at
in the 9 BRN level in the 9 BRN the primary
Regions Regions care level in
the 9 BRN
Regions

121
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Density of Nurses Number of Nurses Number of Total population ÷ 5.60 7.50 HRHIS Quarterly Input zone BRN
and Midwives – and Midwives per Nurses and 10 000 (HRHIS & TIIS region PAF
entire country 10 000 population Midwives 2014) council
(BRN monitors 9 available facility
critical regions HI type
PAF: Reduced star
proportion of brn
Councils with rbf
Nurses and
Midwives < 3 per
10 000
population)

122
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Logistics
Availability of Continuous During During reporting [3 types of [3 types of HMIS Monthly Input zone BRN
Medicines and availability of 10 reporting month: analysis] analysis] Facility survey region
Health Products tracers (medicines, month: 1.[LGA-CCHP] 1.[LGA-CCHP] council
vaccine, medical (1, 2 and 3) Average 7.7 Average > 9.0 facility
device) for 1. Total Number of tracers tracers HI type
essential health number of facilities reporting available in available in star
interventions in a tracers (X number of facilities in facilities brn
facility for a available in reporting months) 2014 (HPPR) 2.[BRN, HSSP rbf
reporting month. facilities 2. [BRN, HSSP IV]
2. Number of IV] All 10 tracers
[3 types of analysis] facilities All 10 tracers available in
1. [LGA-CCHP] having all 10 available in 80% of
Number of tracers tracers; 31%of facilities
available per 3. Number of facilities in [HSSP IV
facility, on average, facilities 2014 2020]; 100%
for reporting having 3.[HSSP IV - of facilities
period; specified Programmes] [BRN 2018]
2. [BRN, HSSP IV] tracer. Specified 3. [HSSP IV -
Percentage of (Sum for tracer Programmes]
facilities having all reporting available in Specified
10 tracers; months) >90% of tracer is
3. [HSSP IV - facilities:5 out available in
Programmes] of 10 tracers >90% of
Percentage of (HPPR) facilities:9
facilities having out of 10
each specified tracers
tracer.

123
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Order fill rate Percentage of items Number of Total number of MSD supplied MSD eLMIS
from supply [value] ordered items [value] items [value] 66 % of items supplied 90
agency that are supplied to supplied to ordered [and 66 % of % of items
[and received by] [and received value] of [and 90 % of
health facility in the by] health orders from value] of
correct quantities facility in the facilities in orders from
with the correct correct 2014 facilities
products quantities
with the
correct
products
Facilities
Utilization
Outpatient New outpatient Total Total population 0.64 0.8 HMIS Monthly Output res RBF GRL10
attendance. (OPD) cases per number of (HMIS 2014) Survey HI type 0
capita in a given outpatients star
year or other presenting brn
period. for a new rbf
condition
Inpatient Number of Total Total population ÷ 2.41 2.50 HMIS Monthly Output res GRL10
admissions Inpatient (IPD) number of 100 (HMIS 2014) HI type 0
admissions per 100 IPD star
population per year admissions brn
rbf
Service quality

124
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Three Star rated Percentage of Number of Total number of NA 50% HMIS Monthly Output zone BRN
primary health primary health primary primary health region
facilities. facilities with 3 star health facilities council
rating or higher facilities with facility
3 star rating HI type
or higher x star
100 brn
rbf
Council
Management
Council annual Percentage of Number of Total number of 20% 45% HMIS (to be Annual Output zone
health plan councils whose councils councils (CCHP added) region
(CCHP) annual plan was whose ANNUAL council
approved according annual plan PLAN 2014)
to first round was
assessment criteria.
approved
according to
first round
assessment
criteria X
100
Percentage of Percentage of Number of Total LGAs 41% 75% CCHP Annual Output zone
council whose councils whose LGAs which assessed (2013/2014) Administrative region
annual annual passed the data
comprehensive comprehensive first round of
Council Health Council Health Plan annual CCHP
Plan (CCHP) (CCHP) performance
implementation implementation assessment (
report (Technical report (Technical & Technical &
& Financial) Financial) passes Financial)
passes the first the first round
round assessment assessment

125
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Environment
Clean water Proportion of Number of Total number of 56% 70% census census Output urban / MDG
population using an persons persons in sample (Census 2012) TDHS interval rural SDG
improved drinking using an TDHS interval GRL10
water source improved 0
water
source: piped
water, public
tap, tube
well, dug
well,
protected
spring, or
rainwater x
100
Sanitation Proportion of Number of Total number of 14% 30% census census Output urban / MDG
population using an persons persons in sample (Census 2012) TDHS interval rural SDG
improved using an TDHS interval GRL10
sanitation facility improved 0
sanitation
facility: flush
toilet,
ventilated
improved pit
latrine (VIP),
or pit latrine
x 100

126
 2015 2020 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
HMIS
Performance
Completeness Proportion of Number of Number of reports 90% 95% HMIS Monthly Output Zone
expected reports reports expected in a given (HMIS 2014) Region
(ANC, L&D, child received in a year or other Council
health, OPD, IPD, given year or period. Facility
FP) submitted in a other period. HI type
given year or other Star
period. Brn
rbf

*Target not adjusted to reflect projected funding. Disaggregation categories Used in national monitoring procedures
NACP SP = National AIDS Control Program Strategic
brn = BRN implementation
Plan
NMCP SP = National Malaria Control Program
edu = educational level of mother or patient / client
Sources: Strategic Plan
NTLCP = National Tuberculosis & Leprosy Control
rbf = results based-finance
SAVVY = Sample Vital registration with Verbal autopsY Program
res = residence: health facility, district, region, zone, urban
Nut TWG = Nutrition TWG
SPD = Sentinel Panel of Districts / rural
TDHS = Tanzania Demographic and Health Survey sex = female / male PAF = Partnership Agreement Framework
THMIS = Tanzania HIV & Malaria Information Survey star = star rating PER = Performance Expenditure Review
wea = wealth quintile RMNCAH = RMNCAH One Plan II

Used in international monitoring procedures

GRL100 = Global Reference List (100 indicators)
MDG = Millennium Development Goals
SDG = Sustainable Development Goals
UHC = Universal Health Coverage

127
Annex 4 BRN Key Performance Indicators

BRN TopLine Key Performance Indicators (KPIs)

These definitions and targets are provisional. They are in process of harmonization with recent HMIS indicator definitions and HSSP IV program targets.

Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Human Resources
for Health
Number of Density of clinicians Number of Total population ÷ 7.74 7.74 HRHIS Quarterly Input zone HSSP IV WHO. A
clinicians and and nurses (Medical clinicians and 10 000 average, in all regions HCMIS region Universal
nurses per 10 000 Officers / Assistant nurses including NGOs need to include council Truth: No
population in the Medical Officers and available in NGOs facility health
BRN Regions Clinical Officers / the BRN HI type without a
Assistant Clinical Regions star workforce,
Officers and Nurses / brn 2013
Midwives) in the BRN rbf p. 18
Regions per 10 000
population
1. Equitable Proportion of regions Number of Total number of tbd 2016: 60% HRHIS Annually Input
distribution of attaining the 2014 regions with regions 2017: 80% HCMIS
clinicians / nurses baseline national average of 2018: 100% need to include
in the BRN Regions average of density of density of 7.74 (BRN) NGOs
skilled HRH per 10k clinicians /
population in the BRN nurses per 10k
Regions. population.
(Precise 2014
density to be
determined.)
2. Utilization of Proportion of Number of Total number of 68% 2016: 75% Source to be Annually Input
employment employment permits employment employment permits (BRN 2013-14) 2017: 80% identified
permits for HRH in for HRH utilized in permits for allocated to MoHSW 2018: 90%
the BRN Regions the BRN Regions HRH utilized by PO-PSM (BRN)
 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
3. Primary Health Number and Number of Total number of 498 2016: 348 HRHIS Quarterly Input zone HSSP IV
Facilities with at percentage of Primary Primary Health dispensaries 2017: 198 HCMIS region
least one clinician / Primary Health Health Facilities in the BRN without 2018: 148 council
nurse in the BRN Facilities with at least Facilities with Regions clinician / -or- facility
Regions one clinician / nurse at least one nurse in 70% reduction HI type
in the BRN Regions clinician / thirteen critical in number of star
nurse x 100 in regions facilities brn
the BRN without rbf
Regions 91% clinician /
(HMIS 2014) nurse
nationwide
In process of
verification (BRN)

98%
(HSSP IV 2020)
Health facilities
4. Primary health Proportion of primary Number of Total number of In process of 2016: 20% system under ??? Output zone HSSP IV
facilities with 3 star health facilities at 3 primary health primary health verification 2017: 60% development region
and above rating in star rating and above facilities with facilities 2018: 80% council
the BRN Regions in the BRN Regions 3 star rating or (BRN facility
higher x 100 in preliminary) HI type
the BRN star
Regions 2020: 50% of brn
facilities rbf
(HSSP IV)

129
 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Health
Commodities
5. Availability of Continuous 1) Total (1, 2 and 3) Number [3 types of [3 types of HMIS Monthly Input zone HSSP IV
Medicines and availability of 10 number of of facilities (X analysis] analysis] region
Health Products tracers (medicines, tracers reporting months) 1. Average 7.7 1. Average > council
vaccine, medical continuously tracers 9.0 tracers facility
device) for essential available in available in available in HI type
health interventions facilities (X facilities in facilities star
in a facility for a reporting 2014. brn
reporting month. [3 months) 2) (HMIS) 2. All 10 rbf
types of analysis] Number of tracers
1. [LGA-CCHP] facilities 2. All 10 tracers available in %
Number of tracers having all 10 available in of facilities.
available per facility, tracers; 3) 31% of
on average, for Number of facilities in 2016: 80%
reporting period; facilities 2014 2017: 100%
2. [Supply chain] having (HMIS) 2018: 100%
Percentage of specified (33%, BRN) (BRN)
facilities having all 10 tracer.
tracers; 3. Specified 2020: 80%
3. [Programmes] tracer available (HSSP IV)
Percentage of in > 90% of
facilities having facilities in 3. [HSSP IV -
specified tracer. 2014: 5 out of Programmes]
10 tracers Specified
(HMIS) tracer is
(33%, BRN) available in >
90% of
facilities: 9 out
of 10 tracers

130
 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
6. Order fill rate Percentage of items Number of Total number of MSD supplied MSD supplied eLMIS Monthly Input zone HSSP IV
from supply agency [value] ordered that items [value] items [value] 66% of items % of items region
are supplied to [and supplied to ordered [and 66% of [and of value] council
received by] health [and received value] of orders of orders from facility
facility in the correct by] health from facilities facilities HI type
quantities with the facility in the in 2014 star
correct products correct (eLMIS) 2016: 80% brn
quantities with (65%, BRN) 2017: 100% rbf
the correct 2018: 100%
products of facilities
(BRN)

2020: 90% of
facilities
(HSSP IV)
RMNCH
7. Prepregnancy
Contraceptive The percentage of Number of Number of women 36% 2016: 50% HMIS HMIS Outcome res HSSP IV SDG
prevalence rate women aged 15-49 active effective between 15 and 49 (HMIS 2014) 2017: 60% Annual wea RBF GRL100
(effective modern years, regardless of modern years of age. 15% 2018: 70% TDHS interval method RMNCAH
methods: depo- marital status, who contraceptive (BRN Lab 2014) edu
provera, pills, have received, or users x 100 RMNCAH star
diaphragm, whose partner has 2020: 60% brn
Norplant, received, at least one rbf
vasectomy, tubal effective modern
ligation) method of
contraception from a
health facility during
the year.

8. Pregnancy
Antenatal care Percentage of Number of Estimated number of 12% 2016: 50% HMIS Monthly Outcome res HSSP IV
coverage: before 12 pregnant women who pregnant pregnant women in (HMIS 2014) 2017: 70% wea RBF
weeks gestational start ANC before 12 women in the the BRN Regions. 18% 2018: 80% edu RMNCAH
age in BRN Regions weeks of gestation BRN Regions (BRN Lab 2014) star
age in the BRN who start ANC RMNCAH brn
Regions before 12 2020: 60% rbf
weeks of
gestation age x
100

131
 Data
Indicator Definition Numerator Denominator Baseline Target Source Frequency Type Disaggr nat'l int'l
Antenatal care Percentage of Number of Estimated number of 28% 2016: 50% HMIS Monthly Outcome res HSSP IV MDG
coverage in the BRN pregnant women in pregnant pregnant women in (HMIS 2014) 2017: 70% wea RBF GRL100
Regions: 4 visits the BRN Regions who women in the the BRN Regions. 43% 2018: 80% edu RMNCAH
received antenatal BRN Regions (BRN Lab 2014) star
care four or more who received RMNCAH brn
times in a given time antenatal care 2020: 90% rbf
period. four or more
times x 100
9. Delivery
Skilled attendant Percentage of Number of Estimated number of ???% 2016: 70% HMIS Monthly Outcome res RMNCAH
delivery coverage in deliveries in the BRN deliveries in deliveries (HMIS 2014) 2017: 75% wea
the BRN Regions Regions attended by a the BRN 70% 2018: 80% edu
skilled attendant Regions (BRN Lab 2014) star
during a specified attended by a brn
time period skilled rbf
attendant x
100
Institutional Percentage of Number of Estimated number of 44.72% 2016: 70% HMIS Monthly Outcome res HSSP IV GRL100
delivery coverage in deliveries in a health deliveries in deliveries in the BRN 2014 data 2017: 75% wea PAF
the BRN Regions facility in the BRN health Regions 2018: 80% edu RBF
Regions during a facilities in the star RMNCAH
specified time period BRN Regions x RMNCAH brn
100 2020: 90% rbf
10. Newborn
health
Postnatal care: Percentages of Number of I: Estimated number I: 65% 2016: 70% HMIS Monthly Outcome res HSSP IV
within 7 days after mothers and of mothers and of live births in the (HMIS 2014) 2017: 75% (to be added) wea RBF
delivery in the BRN infants in the BRN number of BRN Regions M: 68% 2018: 80% edu RMNCAH
Regions Regions who received infants in the M: Estimated (HMIS 2014) star
postnatal care within BRN Regions number of deliveries RMNCAH brn
seven days of who received in the BRN Regions 2020: 80% rbf
childbirth (regardless postnatal care
of place of delivery) within seven
days of
childbirth x
100

132
Annex 5 HSSP IV Specific Objectives Process Indicators
These indicators are monitored in addition to health sector performance indicators and BRN Key Performance Indicators
2015
Baseli 2020 Data
Indicator Definition Numerator Denominator ne Target Source Frequency Type Disaggr nat'l int'l

Strategic Objective 1: Quality

National Availability of revised Revised NEHCIP-Tz in Target Process
Essential Health NEHCIP-Tz which can place 2016
Care serve as starting point for
Intervention Minimum Benefit
Package Package for insurance
Community Percentage of health Number of health Number of health 0 100% CHMT Annual Process
Score Cards facilities apply facilities with facilities where annual
community score cards community score cards were report
scorecards in place introduced
Infection Percentage of Hospitals Number of Hospitals Number of First 100% RHMT Annual Process
Prevention and with functional IPC with functional IPC referral level Annual
Control (IPC) standards standards (= hospitals and report
evidence of actual Regional referral
implementation Hospitals
during supervision
Quality Percentage of Number of training Number of 0 80% MOHSW Annual Process
Improvement (para)medical training curricula audited training curricula HR Dept
Awareness programmes with QI in with modules on audited and QI
curriculum Quality Dept
Improvement
Assessment and
Implementation
 2015
Baseli 2020 Data
Indicator Definition Numerator Denominator ne Target Source Frequency Type Disaggr nat'l int'l

Strategic Objective 2: Equitable access

Annual Analysis Epidemiological analysis Availability of annual See Annual DHIS-2 Annual Process Per
of Inequity of inequities based on analysis of data on BRN analysis Council
development major major health
health conditions conditions from
disaggregated per DHIS-2
Council disaggregated per
Council
Gender equity Percentage of positions Number of women Total number of Council Annual Process Per HF
in health facility in HFGCs held by women in HFGCs HFGCs Health
governing Reports
committees

Strategic Objective 3: Community Partnership

Roll out of Coverage of National Number of Councils Total number of Council Annual Process Per
National Community Health with trained Councils health Council
Community Programme Community Health reports
Health Workers (formal
Programme curriculum)
employed
Dissemination MOHSW website with Functional and MOHSW
of health health education updated website report
information materials, and MOHSW accessible
documentation for health workers
methodology health and general public
promotion

Strategic Objective 4: Effective Management

134
 2015
Baseli 2020 Data
Indicator Definition Numerator Denominator ne Target Source Frequency Type Disaggr nat'l int'l
Analysis and Percentage of planned Monitoring meetings Quarterly MDU quarterly Process
follow up of quarterly monitoring implemented monitoring reports
quarterly BRN meetings taking place satisfactory (= meetings planned
monitoring with information on required
meetings progress documentation
available
PPP Percentage of planned Number of service Number of CCHPs Annually Process
implementation service agreements agreements signed service
realised between LGAs and agreements
private or NGO planned between
providers LGAs and private
or NGO providers
Performance Percentage of HSWG Number of HSWG Number of HSRS Annually Process
Health Sector successful meetings meetings performed HSWGs planned
Working Group with 90% of the (twice per year)
invited participants
present

Strategic Objective 5: Social Determinants of Health

Health Impact Percentage of health Number of Number of cases MOHSW Annually Process
Assessment impact assessment informative health where MOHSW Dept.
implemented impact assessments indicated that Preventiv
implemented Health Impact e Service
Assessment was
needed

135