Tanzania - Population, health and nutrition sector review

Report No. 7495-TA Tanzania Population, Health and Nutritiorn Sector Review October, 1989 Population and Human Resources Operations Division Southern Africa Department FOR OFFICIAL USE ONLY U Document of the World Bank This document has a restricted distribution and may be used by recipients only in the performance of their offici- duties. Its contents may not otherwise be disclosed without World Bank authoriza, %.  CURRENCY EQUIVALENTS Currency Unit Tanzanian Shilling US$1.00 = TSh 145 (May 1989) TSh 1 = US$0.007 GOVERNMENT FISCAL YEAR July 1 - June 30 ABBREVIATIONS AND ACRONYMS AIDS - Acquired Immunodeficiency Syndrome AMO - Assistant Medical Officer BCG - Vaccine to protect against TB cCM - Chama Cha Mapinduzi (the Party) CCT - Christian Council of Tanzania CEDHA - Center for Educational Development in Health, Arusha CMBT - Christian Medical Board of Tanzania cMS - Central Medical Store DANIDA - Danish International Development Agency DC - District Council DEO - Divisional Executive Officer DED - District Executive Director DMO - District Medical Officer DMT - District Management Team DPO - District Planning Officer DPT - Vaccine to protect against diphtheria, pertussis, tetanus DSSD - Dar es Salaam Sewerage and Sanitation Department EDP - Essential Drugs Program EPI - Expanded Program of Immunization ERP - Economy Recovery Program ESAP - Economic and Social Adjustment Program FAO - Food and Agriculture Organization FINNIDA - Finnish International Development Agency FRG - Federal Republic of Germany HA - He&lth Assistant IDD - Iodine Deficiency Disorders IDWSSD - International Drinking Water Supply and Sanitation Decade IEC - Information, Education, Communication ILO - International Labour Office IPPF - International Planned Parenthood Foundation IUD - Intrauterine Device  FOR OFFCIAL USE ONLY ABBREVIATIONS AND ACRONYMS (Continued) JNSP - Joint (WHOIUNICEF) Nutrition Support Programme KfW - Kreditanstalt fur Wiederaufbau MA - Medical Assistant MALD - Ministry of Agriculture and Livestock Development MCH - Maternal and Child Health MCHA - Maternal and Child Health Aide MFEAP - Ministry of Finance, Economic Affairs and Planning, now two separate agencies: Ministry of Finance and Planning Commission MLG - Ministry of Locel Government, Community Development, Cooperatives, and Marketing MOE - Ministry of Education MOH - Ministry of Health MOW - Ministry of Water NAPCO - National Pharmaceutical Company NGO - Non-governmental Organization NORAD - Norwegian Development Assistance NUWA - National Urban Water Authority ODA - Overseas Development Administrrtion (U.K.) OGL - Open General Licansing PHC - Primary Health Care PHN - Population, Health and Nutrition PMO - Prime Minister's Office RDC - Regional Development Committee RHC - Rural Health Center RMA - Rural Medical Aide RMO - Regional Medical Officer RHC - Rural Health Center SIDA - Swedish International Development Authority STD - Sexually Transmitted Disease TB - Tuberculosis TBA - Traditional Birth Attendant TCMA - Tanzania Christian Medical Association TEC - Ta.aiania Episcopal Conference TFNC - Tanzania Food and Nutrition Centre TFR - Total Fertility Rate TPI - Tanzania Pharmaceutical Industries TOH - Tanzania Occupational Health UCI - Universal Child Immunization UMATI - Family Planning Association of Tanzania UNDP - United Nations Development Program UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children's Fund VA - Voluntary Agency VDC - Village Development Committee VHW - Village Health Worker WAZAZI - Tanzania Parents' Association WEO - Ward Executive Officee WDC - Ward Development Committee WHO - World Health Organization This document has a restricted distribution and knay be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  i TANZ IIk POPULATION. HEALTH. AND NUTRITION SECTOR REVIEW TABLE OF CONTENTS Page No. I. EXECUTIVE SUMMARY AND INTRODUCTION ................... 1 Overview .. . **.. ...... I9*. 9.9999.99.99............... 1 Background and Context .. * * * * * * * *..*...*......*...*.*...... ... 4 Issues and Recommendations........................... 6 Slowing the Pace of Population Growth ........... 6 Operationalizing Government's Health Policies ............................................... 9 Alleviating Nutritional Deficiencies............ 16 II. POPULATION ..........................................o.. 20 A. Demographic Situation and Trends ................000 20 Availability of Demographic Data..******....... 20 Population Size, Distribution and Urbanization .................................. 20 Migration...................................... P22 Mortality ........... 22 Fertility ...... 23 Age and Sex Structure. . .oo... o o..... o...... 24 Natural Increase and Population Growth...wt..o.. 25 B. Projections of Population Growtho.......th.......... 26 Methodology. ..... ...*.*.***. **.. ... ... ......... 26 Results of Altern&tive Scenarios...o......rios.. 28 C. Implications of Rapid l!opulation Growth.o............ 30 Impact on Development....................o. 30 Impact on Education and Health....a lt......h.... 33 ____________________________________ (cont.) This report was prepared by Mesdames. Kreszentia Duer, Althea Hill and Jeannette Murphy, based on a mission to Tanzania in November 1987, and follow-up missions in September 1988 and February 1989. The main mission comprised Messrs. John Innes (mission leader), Jean-Louis Lamboray (public health specialist), E.J.R Heyward and Miles Burton (consultants), Mesdames. Althea Hill (demographer) and Neeta Sirur (operations officer).  Pate No. D. Population Policies, Programs and Institutions ...... 38 Population .......................... ......... .. 38 Population Programs and Institutions ......... 0*6 40 Coverage, Quality and Utilization of Family Planning Services .. . . . ....... . . . . .......... . . ... 41 E. Donor Role in the Population Sector.................. 43 AII. HEALTH Suto............... .............*......... ........ 44 A. Health Stain........................... 44 Acute Respiratory Infections .................... 45 )iarrheas........................................... 45 'Da, including AIDS........................ .... 46 tuberculosis ............................... 47 Leprosy ................................. 47 Pregnancy-Related Problemss..................... 48 Nutrition-Related Conditions ........ " .......... 48 B. Health Policy ................................ 48 C. Organization of Health Services ................ 50 Health Fclte .........................e * 50 Government Health Delivery System................. 55 Non-governmental, Industrial and Private Sector ........................ . 62 Utilization and Quality of Health Service0...... 65 D. Health Manpower............................ . 66 Manpower Situation ....... 64*090*4006**.96 0 66 Compensation..**. ........................... 68 Projections of Manpower Requirements......... 70 E. Pharmaceuticals......... .. . ....... 73 Procurement and Distributions...*u.... 73 Local Production..od u.t.io...... . **....... 77 F. Health Expenditures and Financing..*i...... 80 Sources of Funds.... 80 Expenditure Levelvs.e ls. ...... 81 Structure of the Investment Budget.............. 83 Structure of the Recurrent Budget*.,,***,.*,,t 83 G. Donor Role in the Health Sector**..*****... o........ 87  iii Pate No. IV. NUTRITION .......o....................................... 88 A. Nutrition Situation.- .*.. ...... .....* . 88 Introduction .................... 09999999.9.9........... 88 Food Consumption and Diet....................... 89 Prevalence of Malnutrition...................... 91 B. Nutritional Institutions and Policies...9... 94 C. Nuiritional Programs and Interventions................ 95 Nutritional Programs and Projects ............... 95 Nutritional Interventions Through the Health Sector ......... ..** ..... . ............... 97 Nutritional Interventions Through the Water and Sanitatlon Sector.................. 98 Nutrition Education and Interventions Through the Educational System............... 99 Nutritional Interventions Through the Agricultural Sector ............................... 99 D. Donor Role in the Nutrition Sector................... 100 V. ISSUES AND RECOMMENDATIONS IN HEALTH, POPULATION AND NUTRITION................... .................... 101 A. Slowing the Pace of Population Growth ................ 102 Population Policy . ................. 9 102 Family Planning Programs ........................ 103 B. Operationalizing the Government's Health Policies.... 104 Facilitating the Decentralization of Health Services.... ..... 104 Mobilizing Community Self-Help .9............... 107 Improving Capacity at the Central Level ......0.. 108 Increasing Cost-Effectiveness and Mobilizing Additional Resources for the Sectoe... . ............. 111 C. Alleviating Nutritional Deficiencies................. 113 Improving Household Practices.. . . .. . 113 Expending Nutrition Interventions ...... ...... o.* 114 D. Suoiary *9*9******99**999**999*9*999*99*999*99999*99* 116  iv ANN=ES Page No. A. Tanzania Population Projections Constant Fertility .. ...................................... 120 Moderate Fertility ..................... .................. 130 Rapid Fertility Decline................................... 140 B. Organization Structure - Ministry of Health.................... 150 C. Local Government Decision-Making and Budgetary Procedures ...... 151 D. Training of Manpower in the Health Sector ...................... 164 E. Distribution of Health Manpower by Regional Groups#............. 170 F, Public Sector Salaries ......................................... 171 G. Health Manpower Projections .................................... 174 H. Health Facility Staffing Standards as Proposed by Government... 180 I. Projected Health Manpower Requirements by Health Institution... 201 J. Typical Voluntary Agency Hospital Fees, 1987................... 217 K. Regional Recurrent Health Badget, 1987/88.............. . 220 L. Tanzania Food and Nutrition Center e............................ 221 M. Water, Sanitation and Health ................................... 235  v Page No. Tables in Text 2.1 s Population of Tanzania, 1988 by Region . . . . . . . . . . 21 2.2 : Tanzania: Recorded Intercensal Growth Rates, . . . . . . 25 1948 - 1988 2.3 : Assumptions for Population Projections . . . . . . . . . 27 2.4 s Projected Total Population of Tanzania . . . . . . . . . . 28 2.5 s Projected Population Growth Rates . . . . . . . . . . . . . 28 2.6 s Projected Age Structure of the Population . . . . . . . . . 29 2.7 t Projected Population of Working Age (15-64 years) . . . . 30 2.8 s Per Capita GDP Under Various Fertility Scenarios . . . . . 31 2.9 s Projected Demand and Supply of Fuelwood . . . . . . . . . . 33 2.10 s Projected Number of School-Age Children . . . . . . . . . 34 2.11 : Public Recurrent Expenditures for Primary and Secondary Education, 1985, 2000, and 2015 . . . . . . . 35 2.12 s Projected Number of NCH Clients . . . . . . . . . . . . . . 36 2.13 s Projected Government Recurrent Expenditures on Primary Health Under Various Fertility Scenarios . . . . 37 3.1 s Disease Frequency in Sentinel Dispensaries (Jan. 1984 - Aug. 1987) .. . . . . . . . . . . . . . . . . 44 3.2 s Prevalence of HIV Antibodies in Healthy Subjects and Groups of Patients in Three Urban Areas of Tanzania in 1986 . . 47 3.3 t The Health Referral System in Mainland Tanzania . . . . . . .51 3.4 : Health Care Institutions in Mainland Tanzania . . . . . . . 51 3.5 s Total Health Facilities, by Region, Mainland Tanzania, 1988 . . . a . ..................................... .... .. 53 3.6 s Population Served per Health Facility, by Region, Mainland Tansania, 1988 .................54  vi Pate No. 3.7 s Voluntary Agency Medical Service in Tanzanias 1961 - 1971 . . . . . . . . . . . . . . . . . . . . ............. 63 3.8 s Out-Patient Visits per Person 1972 and 1978 . . . . . . . 66 3.9 : P-incipal Categories of Health Personnel (Mainland) . . . 68 3.10 s Existing and Proposed Staffing Standards (Health Personnel) For Lower Level Health Facilities . . . . . . . . . . . .71 3.11 s Manpower Requirements Under Alternative Assumptions . . . 72 3.12 : Total Central Government Expenditures for Health (1980/81 - 1988/89) . . . . . . . . . . . . . . . . . . 82 3.13 : Total Health Expenditures (Mainland) 1986/87 - 1988/89. . .84 3.14 : MOH 1987/88 Development Budget . . . . . . . . . . . . 85 3.15 : Central MOH Recurrent Expenditures Budget, 1988/89 . . . 86 (TSh 000) 4.1 : Kilograms of Staple Foods Purchasable With One Day's Minimum Urban Wage. . . . . . . . . . . . . . .89 4.2 : Nutritional Status of Children Under 5, 1987 . . . . . . 92 4.3 s Estimated Prevalence of Malnutrition in Tanzania 1986-87 .........................93 MAP IBRD No. 19829  CRAPTER I MEXCUTIVE SUMMARY AND INTRODqCTION Overview 1.01 The Government of Tanzania has demonstrated strong cormnitment to the delivery of basic social services, and has made great strides in developing the necessary infrastructure, manpower, and national programs for population, health, and nutrition (PENW) services, especially through expansion of primary and preventive health care. However, serious problems need to be overcome in the quality, effectiveness, and efficiency of the services. While the Government's PHN policies are basically sound, their implementation urgently needs improving. The progress achieved in the social sectors during the 1960s and 19709 has been endangered in the 1980s by the crises affecting the economy and the public sector. Social sector services are starved of resources and risk losing not only their credibility but also their ability to prevent a regression in many key indicators. If decisive action is not taken soon, the progress gained to date could be jeopardized. 1.02 The challenge facing Tanzania in the years ahead is how to develop the institutional capacity (historically a weak area, whatever the sector) and the resource base to move population, health and nutrition services out of their dangerous downturn and into a new ora of devolution and developmet