the way forward Offers of a big new hospital might be tempting- but Tanzania gives top priority to making basic health services available to all of its citizens Tanzania haS been designated by the Uni.ted Nations as one of the world 's " 25 poorest" countries. Its poverty stems from a history described by President Julius K. Nyerere as one in which " We (Tanzanians) have been oppressed a great deal , we have been exploited a great deal and we have been disregarded a great deal. " With the coming of independence in I 961 it became possible for the first time for the country to take hold of its own future. The history of health ser- vice development in Tanzania is not unlike that of the rest of Africa, and much of the rest of the Third World . Initially it consisted of scattered, partial and uncoordinated ef- forts aimed primarily at creating curative ser- vices for the country's urban minority. Al- though the country was dotted with "dispen- saries", these were generally manned by ill- equipped staff only capable of dispensing pharmaceutical palliatives- when these were available. Medical facilities and staff were not only extremely limited in number, but they were not distributed in keeping with the spread of population . Thus the ratio of hos- pital beds per head of population ranged be- tween 1:400 and I: 3,500 in different dis- tricts . Access to health care facilities also varied widely between districts, and so did the use made of them. Annual expenditure on health care averaged 18 Tanzanian shill- ings per head, but varied from 90 shillings in the capital, Oar es Salaam, down to two shillings in some rural areas (seven shill- ings = one dollar US) . As in mosi of the developing countries, the major causes of morbidity and mortality are infectious and parasitic diseases, which are made more serious by a generally low stan- dard of nutrition . All told , poverty-linked diseases account for about three-quarters of all deaths, while the diseases common in af- fluent countries, such as heart disease, are relatively unimportant. The birth rate is esti- 8 BY OSCAR GISH mated at 47 per 1,000 and the crude death rate at 22 per 1 ,000. Infant mortality is thought to be of an order of I 60-165 per 1,000 and expectation of life at birth is only 40 to 45 years. Today there is a fresh emphasis on the need for more rapid rural development. The impetus for this was given at the 1971 bien- nial conference of the national political party TANZANIA IN FIGURES Popu lat ion (total ) (urban ) (rural) Ann ual rate of po pula- t ion increase Cru de birth ra te (per 1000) Cru de death ra te (per 1000) Life expectancy at birth Infant mortality per 1000 live births Population under 15 years Popu lat ion per physicia n Populati on per profes - sio nal nurse GN P per cap ita Heal t h budget as a per- centage of t he to tal budget 13800 000 (73) < 10% (73) > 90% (73) 2.7% (73) 47.0 (73) 220 (73) 40 -45 years (73 ) 160-165 (67) about 50% (73) 2793 5 (73 ) 14919 (73) US$89 (70) 5. 1 (72) Sources : W HO. UN. World Bank. TANU (the Tanganyika African National Union) , when it was resolved that " from now on, the vital needs for water, schools and health shall be given priority in our expendi- tures". The ministries responsible for these services were instructed to move into action at once, and the Ministry of Health was or- dered to translate the Party's decision into specific planning actions . The essence of the problem was to spread the very limited volume of resources avail- able for health care in keeping with the needs of the entire population. This strategy recog- nized the fact the great bulk of illnesses en- countered in countries like Tanzania can be readily prevented and, when need be, easily treated . The techniques required are relatively simple and inexpensive, and depend primar- ily on auxiliary-type personnel for their appli- cation . Tanzania had always placed great stress on the importance of disease prevention, yet in spite of some significant successes this critical area of its health work had achieved only nominal gains. Now the Ministry of Health was reorganized so as to include a Director- ate of Preventive Services (the others are Manpower Development, and Curative Ser- vices), and expenditure on specific preventive programmes has since shown a marked in- crease. However the most dramatic development in Tanzania is the provision of comprehen- sive care through the rural health infrastruc- ture, which combines preventive health cam- paigns with health promoting activities. The actual planning process began with a calculation of the size of the expected recur- rent budget for health in the year 1980 (the end of the next five-year plan). This figure was accepted as the major constraint, along with manpower availability, on the develop- ment of new health programmes and facili- ties during the intervening years . Allowance A village medical helper providing first aid in the Kidomele ujamaa village. Village medical helpers are selected by their fellow villagers. (Photo WHO/D . Henrioud)
was made for additional resources that would become available from non-govern- mental sources, primarily the voluntary ag- encies and external aid bodies. The precise number of new rural and other health units to be constructed was determined within a political perspective that demanded increas- ing equality of access to health facilities for all the population. It was clear that hospital expansion would have to be sharply curtailed if the health ministry was to live within its expected 1980 budget. It was necessary to restrict the in- crease in the number of hospital beds to the growth rate of population; that is, freezing the bed/population ratio at the existing aver- age level of approximately l :750. The rapid expansion of small rural units and the limited increase in the number of hospital beds called for a manpower plan that would pro- vide for a very large "output" of auxiliary workers and a comparatively smaller com- plement of professionals. At the heart of Tanzania's rural health planning are the "ujamaa villages", rural developments whose members join in com- munal farming and social improvements on a basis of "love, sharing and work". Ujamaa, which means familyhood in Swahili, denotes the special obligations required in extended family relationships. About three million people, almost one quarter of the rural in- habitants, are now living in these villages, and it is intended that the entire rural popu- lation will have "gone ujamaa" by next year. The two main objectives behind this policy are: grouping of families geographically to 10 make it easier for the government to provide such essential services as adequate and wholesome water supplies, education and basic health services ; and to raise the pro- ductivity of the villages so as to combat more effectively the vicious cycle of poverty, ignor- ance and disease. Thus the ujamaa village policy indirectly contributes to the general betterment of the nation's health. The ujamaa concept is closely bound up with Tanzania's avowed aims of socialism and self-reliance. The Arusha Declaration of 1967, TA NU's basic policy statement, defined the path of socialist development as : the ab- sence of exploitation; retaining the major means of production and exchange within the control of peasants and workers; the ex- istence of democracy; and belief in socialism as a way of life, especially among the leader- ship of the nation's organizations. Self-reli- ance was proclaimed as essential to this par- ticular form of development. It also meant an end to privilege and leaders are prohibited from holding shares in any company, being a director in any privately owned enterprise, receiving two or more salaries, owning a house which is rented to others, or being associated in any way with the practices of feudalism or capitalism. The Arusha Dec- laration very clearly points out that a state is not socialist simply because all the means of production are controlled and owned by government. Everything depends upon how, and for whose benefit, that control is exercised . Something of the importance of the uja- maa principle was conveyed by President Above: A patient being examined by a quali- fied nurse in the Lugoba health centre, in Tan- zania. (Photo WHO/D. Henrioud) Opposite page top: A doctor interviewing a patient in the Bagamoyo district hospital. There were 494 medical graduates in Tanzania in 1972, of whom 195 were nationals. (Photo WHO/ D. Henrioud) Right: A fourth-year student nurse tutor in the library of the Dares Salaam school of nursing. ( Photo WHO/D. Henrioud) Nyerere in the same year as the Arusha Dec- laration, when he said: "A nation of such village communities would be a socialist nation. For the essential element in them would be the equality of all members of the community. The country would also become more democratic through this organization of ujamaa communities .. . Not only would the people be governing their own lives directly in village matters, but they would also be playing a more effective role in the government of their country." Let us now see how Tanzanian socialism operates in providing health facilities for all the people. Today village health posts, the most basic unit in the rural health infrastructure, are usually located in ujamaa villages. The post provides treatment for minor ailments and also offers first aid for more serious illness and injury. More important is its function as the basis for health campaigns . Posts do not usually function in a separate building but are more often located within a school or other public structure. As the village grows the post may be upgraded to dispensary level. There are now more than I ,550 dispensaries in Tanzania, 300 of which are operated by the voluntary agencies. Each year until 1980 another 100 dispensaries will be built, result- ing in an average ratio in that year of one dispensary to 6,500 rural population . New dispensaries are . allocated in keeping with population/dispensary ratios (by district), accessibility to existing health facilities , and the percentage of population living in ujamaa villages . The main function of the dispensary is to provide outpatient care and serve as a centre for organizing and running health campaigns. A standard dispensary has two maternity beds . The usual design is a two-roomed building providing areas for waiting, examinations, treatment, storage and a laboratory " corner" . There is also a latrine and one staff quarter. The two-bed maternity hut, the latrine, and some elements of the main building are included in the design as a "self-help" element. The capital cost of the dispensary "complex" is now around US$7,000. The key staff at a dispen- sary are a rural medical aide and a maternal and child health aide. The operating cost of such a dispensary is about US$4,000 per an- num. There are now more than I 00 rural health centres in the country. Each year until 1980 another 25 rural health centres will be built, to give an average ratio in that year of one rural health centre to 50,000 rural popula- tioq. New rural health centres are mostly allocated in accordance with popula- tion/rural health centre ratios (by district) and accessibility to existing health facilities . Rural health centres are capable of providing the broad range of preventive and curative services required by rural populations. They function in relationship to surrounding dis- pensaries, on the one hand, and to the dis- trict hospital, on the other. A standard rural health centre has an outpatient building, a public health structure, a ward containing 14 beds (6 maternity and 8 holding), a service block, and staff housing. The capital cost is about $75,000. The centre is staffed by 10 auxiliaries headed by a medical assistant (there are also 6 ancillary staff). The operat- ing cost of such a health centre is close to $25,000 per annum. In addition to the services described above there is a broad range of mobile activity whereby visiting health workers provide both preventive and curative services, including health and nutrition education, communi- cable disease control, the improvement of environmental sanitation, and maternal and child health clinics. Hospital expansion is no longer a priority area. There are 123 hospitals in the country (half of them run by the voluntary agencies), containing a total of about 18,000 beds. Ap- proximately 300 beds per year will be needed to cater for the roughly 3 per cent increase in population. These additional beds will be al- located primarily to those district hospitals 11 which now have the least beds to population, although consideration will a lso be given to such factors as bed utilization and hospital- based training schemes. The per bed capital costs of a new hospital range from $4,000 to $25,000, and the annual operating costs from $1,000 to $4,000. Manpower. The country's modest financial resources are also a constraint on the devel- opment of manpower and heavy emphasis is laid on the minimization of costs. The cost of training a graduate doctor in Tanzania is around $40,000, but the comparable cost of training medical assistants and rural medical aides is less than $2,500 and $2,000 respec- tively: the cost of employing these different cadres also varies very widely. Given the lim- ited catchment areas of health facilities and the costs of providing different types of med- ical manpower, it is apparent that most pri- mary health care in Tanzania must be deliv- ered by auxiliary personnel for very many years to come. The more important primary health workers are described below. Village medical helpers are selected by fel- low villagers, when they leave primary school after seven years of schooling, to undergo 3-6 months of training at a district hospital. Their training enables them to treat minor ailments, provide first aid for more serious problems, and help in the prevention of com- mon diseases. In an ujamaa village, the vil- lage medical helper is supported by the vil- lagers, with a rural health centre providing overall supervision . Maternal and child health aides (MCH aides) will work primarily at dispensaries and rural health centres. They will organize maternal health (including antenatal , deliv- ery, postnatal and family planning), and child health (under fives and school health) services; they will also organize health and nutrition education at village level. There will be one MCH aide school in each of Tanzania 's 19 regions, offering a standard 18-month curriculum that includes six months of practical field training. Minimum selection to training will be from amongst primary school leavers. It is intended that 2,500 MCH aides will be in employment by 1980. Health auxiliaries are also drawn into training from a primary school background, although many have had previous experience in health or community development work. They are employed at rural health centres and dispensaries . The expansion of this cadre is also proceeding ; two new schools are being developed, and 800 auxiliaries are expected to be in employment by 1980. Medical practitioners. Tanzania has had for a long time four distinct types of medical Left: Assembling a hand-pump in a foctory in Dar es Salaam. In Tanzania self-reliance is considered essential for self-supporting health services. It implies thinking in terms of what is available, or can be made available, at comparatively small cost. ( Photo WHO/ D. Henrioud) practitioner (aside from the medical special- ist/consultant). Of these four types only the university graduate is to be found in the Medical Register: this type of practitioner has had a full secondary education followed by a university medical course of five years, plus one year of preregistration medical em- ployment. A second type of medical practi- tioner is the assistant medical officer (AMO). The AMO is originally trained as a medical assistant (MA) and then has at least four years of work experience plus an additional 18 months upgrading course. The medical assistant, in turn, has 11 years of schooling plus three years of medical training. The final category of Tanzanian medical practitioner, the rural medical aide (RMA), differs from the MA in that he has only seven years of (primary) schooling before his three years' medical training. The number of rural medical aides in em- ployment mainly at dispensaries and rural health centres, will have risen by 1980 from around 600 to 2,800 (the output from 16 schools). The RMA is replacing the dispen- sary assistant (formerly known as tribal dres- sers). They are intended to function primari- ly as substitutes for the physician (as are the MA and AMO) and not necessarily as their assistant. The five existing schools for medical assis- tants plus two others that are planned will by 1980 have increased the number of medical assistants in Tanzania from fewer than 400 to 1 ,200. Medical assistants are in charge of the rural health centres, do much of the hospital outpatient work, and will be increasingly taking part in preventive campaigns and pro- grammes. The number of assistant medical officers will rise from over 100 to 300 during the rest of this decade. AM Os have been doing work that is often indistinguishable from that of a graduate physician, for example acting as district medical officers. Along with the other types of non-graduate practitioners (RMAs and MAs), the AMO is usually the only " doctor" known to the people in the coun- tryside. Because Tanzania must continue to rely heavily on medical auxiliaries for a very long time for the delivery of primary medical care it is especially important that their career prospects be carefully worked out. This has now been done. For example, the way is now open for a rural medical aide to become a graduate doctor by undergoing officially ap- proved upgrading courses. Tanzanian graduate doctors are now being trained primarily within the country. It is planned that by 1980 citizens will comprise all but 100 or so of the slightly more than 800 doctors expected then to be in employment. (There are now 500.) Virtually all the national doctors are expected to be working in the public sector. Postgraduate training for the major specialities is being conducted at Tanzania's medical school and close to 200 specialists will have been trained by 1980. Local training in keeping with planned targets is also going ahead for registered and Medical practitioners in Tanzania: Independence to 1980 1961 1970 1971 Training 1972 Train ing 197 3 Training 1974-1980 Planned intake intake intake Planned 1980 annua l train ing intake Graduate doctors 403 1 489 479 48 494 2 48 - 64 64 8003 Assistant medical officers 22 100 115 22 140 - - 24 30 300 Medical ass istants 200 285 289 115 335 146 - 201 2104 1. 200 Rural medical aides 380 473 544 124 578 146 - 338 5604 2.800 --- = not avai lable. 1 Of th e tota l : 35% in government service; 20% employed by th e vo luntary agencies (missions); and 45% in private pra ct ice. Of the 403 medica l graduates only 12 were nationals. 2 Of th e total : 62% in government service; 23% employed by the vo luntary agencies; and 15% in private practice. Of the 494 medi ca l graduates. 195 were national s. 3 Of th e 800 med ical gradu ates, all but 100 or so wi ll be nat ionals. 4 Wastage from training approximately 15%. enrolled nurses, dental assistants and techni- cians, pharmaceutical and dispensing assis- tants and auxiliaries, radiographers and radiographic assistants, laboratory techni- cians and auxiliaries, health education offic- ers and physiotherapists . Traditional medical practitioners are not yet integrated into the organized health ser- vices; however, bilateral aid from a country with considerable experience in the coordina- tion of these two systems is expected soon. Tanzania is spending approximately US$3 per head for health care, or 3 per cent of its gross national product, not including water supply, sanitation, nutrition and other less direct but critical determinants of health . The country's health policy is reflected by the changing pattern of expenditure of the development budget. Health development budget expenditures in Tanzania: 1969/70-1974/75 (in percentages) 1969 / 1970/ 1971/ 1972/ 70 71 72 73 Hospital and anci llary services 63 52 a 52• 27b Rural health cent res and dispensaries 7 24 33 35 Preventive services 9 1 2 10 Training 16C 22 C 13C 18d Manufacturing 5 1 0 10 a About two -thirds in Dar es Sa laam. b Less than 10% in Dar es Sa laam_ c Around 85% in Dar es Sa laam. d Less th an 2% in Dar es Sa laam. 1973/ 1974/ 74 75 15b 12b 33 24 2 8 48d 55d 2 1 From th e table it ca n be seen that during th e three yea rs 1969 -1972 over halfthe development budget had go ne into hospital services (of which two - thirds were spent in Dar es Sa laam). but over the last three yea rs hospita l expendi ture has fallen to only slig ht ly over a tenth of t he budget (and on ly a fraction in Dares Salaam) _ Hospital constructi on has been replaced by expenditure on rural health ce ntres and dispensaries and the bui lding of schools for the tra ining of rural wo rkers. The recurrent budget is also changing in response to the country's new health policies. From 1970/71 to 1974/75 the hospital ser- vices' share of the budget declined from 80 to 60 per cent, while rural health centres and dispensaries more than ·doubled their share from 9 to 19 per cent : preventive services increased from 5 to 12 per cent, and training expenditures rose from 2 to 6 per cent. Al- though the health care system as a whole will cost more with each passing year, it should not rise beyond Tanzania's capacity to finance. The most important decision in this respect has been the one to control the in- crease in the number of hospital beds. Other steps are also being taken to control the costs of drugs and other health service inputs. The system described here is rooted in Tanzania's desire to -provide basic health care to its entire population. This desire stems from a policy of self-reliance that rec- ognizes that no country can be truly indepen- dent while its people suffer from poverty, ignorance and disease. The problems facing Tanzania are enormous, but some critical first steps toward solving them have been taken. Very limited health care resources are being spread thinly so as to maximize the possibility of complete coverage of the popu- lation with minimally required services. This overaJl approach, aimed at increasing the coverage and utilization of primary health care services in rural areas, requires a cut back in the provision of sophisticated and usually expensive but less accessible services. Reorganization of the countryside and mass mobilization are being used as a deliberate political tool to raise the social consciousness of health as the people's own responsibility. The commitment and continuity of Tanza- nia's present health care policies were spelled out in a statement by President Nyerere to the 1973 TANU conference: "We must det- ermine to maintain this national policy and not again be tempted by offers of a big new hospital, with all the high running costs in- volved - at least until every one of our citizens has basic medical services available to him." • 13