Last July, I traveled to Tanzania for a 2 week trip as research team member for the r4d project on health system governance. The goal of the visit was twofold: first, it was an opportunity for newbies to get to know the setup in Tanzania (one of the two countries part of the project) as well as our local partners; second, collect as much information as possible to develop detailed research plans.
Apart for some (well deserved) relax during the weekend, we spent two intense weeks traveling from Dar es Salaam to Dodoma (the region hosting the national capital), Morogoro region and then to Dar es Salaam again. In each location, our super-efficient local partners at IHI (Ifakara Health Institute) arranged tight schedules of meetings with various stakeholders as well as field visits to hospitals and smaller health facilities and dispensaries.
The first impressions on the country is of course positive. Tanzania is relatively quiet (socially and politically). Poverty is a huge problem; about 28% of people lives below the national poverty line in 2011 according to World Bank estimates, while the others are for most part marginally better off. Despite these figures, people in rural areas appeared often happier than the busy people you can run into in the streets of Lugano or Zurich, living with absolute dignity their status.
The relative importance of tourism in the national economy is not surprising. Mother Nature did an amazing job in Tanzania, making it a country definitely worth visiting as a tourist; the island of Zanzibar, the Mount Kilimanjaro, the limitless Serengeti National Park and the Victoria Lake region are just some of the hot spots. Unfortunately, I was not there to explore nature.
What is also striking, in my opinion, is the untamed growth of urban areas such as the economic center of Tanzania, Dar es Salaam. This coastal city has a huge extension and no sense of order whatsoever, which is fascinating to some extent but also disorienting for people born and raised in Switzerland, like me. You can find tarmac and (very) bumpy dirt roads with almost equal likelihood, and driving through a slum you can find yourself in a rich neighborhood close to the Oceanside just crossing a street.
Turning to the health system, the situation is clearly very different from what we experience in Switzerland.
In urban areas such as Dar or Dodoma, public hospitals have a relatively good standards and there is also a number of private hospitals and practices available to the wealthiest individuals that can afford treatments there. Nevertheless, in poor suburbs of cities, life isn’t easy (no jobs, no sanitation, pollution, …) and from a health perspective can be no less complicated than that of fellow citizens out in the remote areas of the country. In Tanzania there is a national health insurance scheme covering a limited share of population, essentially in the formal sector. For rural population, in the last couple of years efforts have been made to promote the spread of community-based health insurance schemes (often referred to as community health funds, or CHF’s). People not covered by an insurance scheme and not exempted/waived have to pay forfait out-of-pocket fees for treatments and medicines (children, pregnant women and elderly are exempted by policy, people recognized as poor are granted a waiver).
In rural areas, people in need of health care refer almost exclusively to public health facilities for two trivial reasons: (1) there are no private health facilities (with the exception of pharmacies) and (2) the economic conditions of people on average would not allow to visit private facilities anyway.
The structure of the health system follows broadly the administrative government structure in that there are 3 essential levels: regions (with regional referral hospitals), districts (with district referral hospitals) and ward/villages (with local health facilities or dispensaries). Usually, the “perceived” quality of health facilities increases with the administrative level but exceptions may exist. Based on the standard the we are used to, few people would probably dare to get a treatment in primary or secondary facilities in Tanzania. On the other hand, some regional hospitals have a fair level of infrastructures, comparable to western countries (maybe with a few notable exceptions like Switzerland, Lichtenstein and the like). Unfortunately, again, regional referral hospitals can be reached by a limited number of citizens. The others, living in remote areas of the country out in the Savannah, may strive even to reach the closest dispensary or primary care center due to long distances, absence of mean of transportation and so on.
Now, given the setting described above, even a perfectly functioning and responsive public health system would have a hard time in providing health care to all those in need (and not only to those who can afford paying high fees and private care). Instead, authorities in Tanzania (similarly to governments in other LMIC’s) face a number of challenges running the public health system; problems go from health financing, lack of investments on maintenance or stockouts in drugs and medical supply to health workers absenteeism, poor management of health facilities and corruption. The list of problems provided here is neither comprehensive nor accurate in describing the situation, but should be enough to convey the message.
Our project is just an infinitely small part or the huge mass of work in development and cooperation out there. What characterizes the r4d programme as well as other similar initiatives is work on evidence-based, research-rooted and policy-relevant issues contributing to the scientific and policy debate in the countries themselves. This organic approach is in contrast (not in competition though) with the common philanthropic perspective made of initiatives focused on mere implementation (no matter if implementation is evaluated and assessed). The latter, despite being invaluably precious at local level and of immediate effectiveness, in my opinion fails to provide the long-term effects that can change things once and for all.