Healthcare in Tanzania

AIDS awareness sign in Dar es Salaam, Tanzania

Health care in Tanzania is available depending on one's income and accessibility. People in urban areas have better access to private and public medical facilities. Insurance has only in recent years been introduced where as pension schemes have been around longer but the limitations of either are vast and not attending to the needs of majority of Tanzanians.

Health care financing

Health care financing is among the key component of a functional health system.[1] Financing involves three aspects, namely revenue collection, risk pooling, and purchasing.[2] In recent years, there has been a growing demand for access to high-quality and affordable care for all, thus the government is committed to respond with a process of developing health financing strategy[3] is underway since early 2013. An inter-ministerial steering committee has been developed, composed of key ministries and department to ensure that the proposed reforms meet the needs of the population. Improving the prepayment mechanisms are the main agenda in the development of the strategy, which is assumed to be a potential facilitator in the progress towards UHC.

The evolution of health care financing in Tanzania

The Arusha Declaration in 1967 was initiated by the president Julius Nyerere, outlining the principles of Ujamaa (Nyerere vision of social and economic policies) to develop the national economy.[4] It marked the start of a series of health sector reforms with the intention of increasing universal access to social services to the poor and those living in marginalized rural areas. Followed by the Government banning private-for-profit medical practice in 1977 [5] and took on the task of providing health services free of charge.

However, by the early 1990s, the strain of providing free health care for all became evident in the face of rising health care costs and a struggling economy. Early 1990s the government adopted health sector reforms that changed the financing system from free services to mixed financing mechanisms including cost sharing policies. Cost sharing in the form of user fees was introduced in four phases: Phase I from July 1993 to June 1994 to referral and some services in regional hospital; Phase II from July 1994 to December 1994 to regional hospital; Phase III from January 1995 onwards to district hospital and Phase IV introduced to health centre and Dispensary after completion of introduction to all district hospital. Exemption and waiver were integral part of the cost sharing policy introduced in 1994.

Health spending

Current data shows in Tanzania there has been an increase in health budget over the years: Total Health Expendinture (THE) increased from US$734 million in 2002/2003 to US$1.75 billion in 2009/2010 as indicated in the National Health Accounts 2010 report. However donors has been the main financier of health, despite the decrease in their share of health expenditure from 44 percent in 2005/2006 to 40 percent in 2009/2010.[6] (Table 1). Overall, the government allocation to health spending has remained almost constant at about 7 percent since 2002/2003, far away from reaching the Abuja declaration target of 15% of total government expenditure. The increase in donor funding is attributed to the commencement of financing for HIV and AIDS by the Global Fund in 2001 and the commencement of health financing through Sector wide Approach (SWAp)[7] in early 2000.

Table 1: Financing sources as a % of Total Health Expenditure[8]

2002/2003 2005/2006 2009/2010
Public 25.4 28.1 26
Private 47.1 27.8 34.4
Donors 27.4 44.1 39.6

On the other hand, there has been a commitment to expand the insurance coverage in the country, however the insurance schemes are highly fragmented.[9][10] There are four health insurance schemes which are publicly owned, namely National Health Insurance Fund (NHIF),[11] Social Health Insurance Benefit (SHIB) established as a benefit under the National Social Security Fund (NSSF)[12] and the Community Health Fund (CHF) [13] and Tiba Kwa Kadi (TIKA). Recent statistics shows that there were about 7 private firms as indicated in the Tanzania Insurance Regulatory authority (TIRA) [14] which were providing health insurance per se, while a few of other general insurance firms combine health insurance benefit under life insurance.[15]

National Health Insurance Fund (NHIF)

The NHIF was established by the Act of Parliament No. 8 of 1999 and began its operations in June 2001. The scheme was initially intended to cover public servants but recently there have been provisions which allow private membership.[16] The public formal sector employees pay a mandatory contribution of 3% of their monthly salary and the government as an employer matches the same. This scheme covers the principal member, spouse and up to four below 18 years legal dependants. There has been a steady increase in coverage from 2.0% of the total population in 2001/2002 to 7.1% in 2011.[16]

Social Health Insurance Benefit (SHIB)

Social Health Insurance Benefit (SHIB) is part of the National Social Security Benefits introduced in 2007. All members of NSSF have access to medical care through SHIB after undergoing registration process with only one facility of their choice. The scheme accredits both public and private providers.The benefit is part of their 20% contribution to the NSSF.[17]

Community Health Fund (CHF) and Tiba Kwa Kadi (TIKA)

Community Health Fund is the scheme that targets the largest population in the rural informal sector and membership is voluntary. There is a counterpart called TIKA which mainly targets the informal sector individuals in urban areas. The CHF and TIKA are both regulated under the CHF act 2001 and managed at district level. At the district level, council health service boards (CHSB) and health facilities governing committees (HFGC) are responsible to oversee the operation of CHF and sensitization. In 2009 the National management role of CHF was given to the NHIF.[18]

Private insurance schemes

Strategis[19] was one of the first registered (2002) private health insurance firms in Tanzania. Members of Strategies insurance are corporate employees that they become members through their company.

AAR [20] is another private health insurance in Tanzania. The firm started as a health-maintenance organisation (HMO) in 1999 but in 2007 it was re-registered as a private health insurance company.

Jubilee Insurance, Resolution Health and Metropolitan Insurance are other examples of private health insurance firms with more less similar features as strategies and AAR.[21]

Health insurance coverage

Health insurance coverage is still low in Tanzania. As of June 2013 NHIF was estimated to be covering about 6.6% of the population while CHF covers about 7.3% of the population based on 2012 Census. Beneficiaries of NHIF includes the contributing members, spouse and up to four dependants. The CHF beneficiaries include head of household, spouse and all children below 18 years. Other prepayment schemes cover less than 1% of the population. CHF mainly focuses its coverage in rural population while private health insurance schemes target urban population. Low insurance coverage leads to overreliance on direct payment at the point of use of health care, which is among the fundamental problem that restrain the move towards universal health coverage in many developing countries.[22] Direct payment can lead to high level of inequity, and in most cases denying the poorest access to needed health care.[23]

Disease

Malaria Clinic in Tanzania in partnership with SMS for Life program which organizes malaria vaccine delivery

Tanzania faces a "mature", generalized HIV epidemic. Among the 1.4 million people living with HIV/AIDS, 70.5 percent are 25 to 49 years old, and 15 percent are 15–24 years. In young women ages 15 to 24, there is an HIV prevalence rate of 3.8 percent, which is significantly higher than the 2.8 percent prevalence rate among young men in the same age group. More than half of available hospital beds are occupied by HIV-infected persons.[24]

Malaria exists throughout the year and is predominantly due to P. falciparum.[25]

Maternal and child healthcare

The 2010 maternal mortality rate per 100,000 births for Tanzania is 790. This is compared with 449 in 2008 and 610.2 in 1990. The UN Child Mortality Report 2011, reports a decrease in under-five mortality from 155 per 1,000 live births in 1990 to 76 per 1,000 live births in 2010, and in neonatal mortality from 40 per 1,000 live births to 26 per 1,000 live births.[26] The aim of the report The State of the World's Midwifery is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 – Reduce child mortality and Goal 5 – improve maternal health. In Tanzania there are only two midwives per 1,000 live births; and the lifetime risk of death during delivery for women is one in 23. [27]

Maternal and Child Health Status

Both maternal and child health are interdependent and substantially contributing to high burden of mortality worldwide. Every year, 289,000 women die due to complications in pregnancy and childbirth, and 6.6 million children below 5 years of age die of complications in the newborn period and of common childhood diseases.[28] Sub-Saharan Africa (SSA), which includes Tanzania, contribute higher proportion of maternal and child mortality. Due to considerable proportion of mortality being attributed by maternal and child health, the United Nations together with other international agencies incorporated the two into Millennium Development Goals (MDGs) 4 and 5. In this regard, Tanzania through the Ministry of Health and Social Welfare (MoHSW) adopted different strategies and efforts to promote safe motherhood and improve child survival. Similarly, in an effort to improve maternal and child health, Tanzania’s government has declared maternal and child health services to be exempt from user fees in government facilities.

Maternal health indicators

Maternal mortality ratio

Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. Statistically, maternal mortality contributes to only 2.3 per cent of the total mortality.[29] The maternal mortality ratio (MMR) represents the risk associated with each pregnancy.[30] MMR is estimated by using both number of maternal deaths and live births. Many low-income countries have no or very little data and modelling is used to obtain a national estimate.[30] According to estimates in 2013, total maternal deaths and MMR in Tanzania were 7,900 and 410 per 100,000 live births respectively.[31] In relation to MDG 5, Tanzania is supposed to reach the MMR of 230 per 100,000 live births by 2015. Reduction of maternal deaths is one of the main goals of the Tanzanian poverty reduction strategy[32] and the health sector reform program, but progress has been slow. The slow progress in reducing maternal mortality on mainland Tanzania is compounded by the impact of the HIV/AIDS epidemic.[29]

Antenatal care coverage

Good care during pregnancy is important for the health of the mother and the development of the unborn baby.[33] Many health problems in pregnant women can be prevented, detected, and treated during antenatal care visits with trained health workers.[34] The World Health Organization recommends a minimum of four antenatal care (ANC) visits. The Tanzania Demographic and Health Survey 2010 showed that 98 percent made at least one ANC visit and 43 percent made four or more visits.[35]

Skilled birth deliveries

This indicator is directly linked to a process of giving birth by pregnant woman, and most of maternal mortality are likely to happen at this stage. Most maternal deaths result from haemorrhage, complications of unsafe abortion, pregnancy-induced hypertension, sepsis and obstructed labour.[36] However, these proportions of causes for maternal deaths are likely to differ from one country to another. According to official estimates, more than 20 women die of pregnancy and childbirth-related complications every day in Tanzania.[37] Ensuring that mothers have access to a skilled attendant during labour can dramatically reduce the risk of death for the mother and newborn child.[38] In the 2010 Tanzania DHS, about 51% of deliveries were assisted by skilled personnel. While it was 41% in 1999 Tanzania DHS. Potentially the current figure national-wide will be more than 51 per cent. Shortage of health providers, among others, are limiting factors to be delivered by skilled provider. The ratio of doctors to patients in Tanzania is 1:25,000 and the ratio of nurses to patients is 1:23,000. While the ratio in the United States is 1:300.[39] President Jakaya Kikwete on May 2014 appealed to health workers in Tanzania to ensure that lives of women and children are not at risk during delivery.[40] In Tanzania, two thirds of women give birth in their own homes, because there are very few health facilities within reach that can provide life-saving emergency services.[41]

Postnatal care coverage

Every year in Africa, at least 125,000 women and 870,000 newborns die in the first week after birth, yet this is when coverage and programmes are at their lowest along the continuum of care.[42] Since up to 50 per cent of maternal deaths occurs after delivery, a midwife or a trained and supervised Traditional Birth Attendant (TBA) should visit all mothers as soon as possible within the first 24–48 hours after birth.[36] The 2010 figure in utilizing postnatal care in Tanzania was only 31 per cent according to TDHS.[43] Coverage of postnatal check-up within 4 hours after birth varies from 9 percent in the Lake zone to 34 percent in the Southern zone in Tanzania.[43] Postnatal care (PNC) programmes are among the weakest of all reproductive and child health programmes in Tanzania and Sub-Saharan African in general.[42] Given the absence of PNC guidelines in Tanzania, the Reproductive and Child Health Section (RCHS) of the Ministry of Health and Social Welfare [Tanzania] reported in 2009 that is in the process of developing it to be used country-wide.[44]

Modern family planning use

The policy environment for family planning in Tanzania is mixed, but promising. At the 2012 London Summit on Family Planning, President Kikwete highlighted Tanzania's continued efforts to improve family planning. He mentioned the National Strategy for Growth and Reduction of Poverty (MKUKUTA II) which has a strong family planning component, and the National Family Planning Costed Implementation Plan (2010) which endeavors to reach a contraceptive prevalence target of 60% of all women by 2015 and will require $88.2 million between 2010 and 2015.[45] Like many countries in sub-Saharan Africa, Tanzania's once successful family planning program has slowed markedly, with rates of contraceptive prevalence well below levels needed to reach current demand and country goals.[46] In Tanzania, 34.4 percent of married women in 2010 reported use of any method of contraception, while modern methods reached a prevalence of 27.4 per cent.[43] Factors limiting contraceptive prevalence in Tanzania include widespread misconceptions and concerns about side-effects, low acceptance of long–acting methods, erratic supplies and a limited range of choices, gaps in provider knowledge and skills (along with provider bias), competing priorities pursuing scarce resources, limited male involvement, poor communication between spouses, and the perceived value of large families also contribute to low use of family planning methods.[47]

Child health indicators

Infant and under-five mortality rate

Children in sub-Saharan Africa are about over 16 times more likely to die before the age of five than children in developed regions.[48] Tanzania has reduced the infant mortality rate (IMR) of 101 to 38 per 1000 live births from 1990 to 2012 respectively.[31][43][49] Also, it has reduced substantially the under-five mortality rate (U5MR) of 166 to 54 per 1000 live births from 1990 to 2012 respectively.[31][43][50]

Malaria is the leading cause of death for Tanzanian children and is a major cause of maternal mortality.[51] Tanzania is making considerable progress in the reduction of child mortality.[52] In that respect, Tanzania is likely to achieve MDG 4 of reducing child mortality.[53] The most significant contribution to the reduction of under-five mortality is improved control measures of malaria, Acute Respiratory Infections, diarrhea; improved personal hygiene, environmental sanitation; and preventive, promotive as well as curative health services.[53] Tanzania's average annual rate of reduction of child mortality over the last 15 years was 4.6%, while, the Millennium Development Goal rate set by UN is an annual average rate of reduction of 4.3 percent.[54]

Vaccination coverage

In the recent past, Tanzania has been in a process of revitalization, with improvements in the planning process, community ownership and involvement, improving coverage, effective mobilization of funds for Expanded Program of Immunisation (EPI), improvements in safety of vaccine delivery and introduction of new and underutilized vaccines.[55] According to 2010 Demographic and Health Survey (DHS) in Tanzania, 66 per cent at 12 months of age were fully immunised during the survey.[43] The 2010 DHS in Tanzania which is the latest, presents the BCG coverage of 95.5%, Diphtheria tetanus toxoid and pertussis (DTP3) coverage of 88%; Polio (Pol3) coverage of 84.9% and Measles coverage of 84.5%. The proportion of children vaccinated against measles increased from 80 per cent in 2005 to 85 per cent in 2010.[53] But the vaccination coverage in Tanzania presented to be more that 90% for each of the above vaccines according to World Health Organization in 2012.[56]

Year BCG DTP3 Pol3 Measles
DHS 2010[43] 95.5% 88.0% 84.9% 84.5%
WHO 2012 [56] 99.0% 92.0% 90.0% 97.0%

The government of Tanzania via the Minister of Health and Social Welfare, has urged in 2012 that partners and stakeholders in the country to join the National Immunization Coordination Committee to ensure that all children in Tanzanian are covered.[57]

Exclusive breastfeeding

In Tanzania by 2010, breastfeeding was initiated within the first hour of birth in 46.1% of mothers.[58] Over 97 percent of mothers in Tanzania do breastfeed, however, the prevalence of exclusive breastfeeding in infants aged 0–6 months is 50 percent.[43][59] Although the national average reported to be 50% prevalence, one regional study focusing on Kilimanjaro region only revealed the general prevalence of 88.1% at one month, 65.5% at three months and 20.7% for an infant of six months of age, which is very low and did not vary between rural and urban.[60] A multivariate analysis using 2010 TDHS data [60] revealed that the risk of delayed initiation of breastfeeding within 1 hour after birth was significantly higher among young mothers aged <24 years, uneducated and employed mothers from rural areas who delivered by caesarean section and those who delivered at home and were assisted by traditional birth attendants or relatives. The risk factors associated with non-exclusive breastfeeding, during the first 6 months, were lack of professional assistance at birth and residence in urban areas.

Child malnutrition

Malnutrition in Tanzania is a contributing factor in an estimated 130 child deaths every day.[61] According to 2010 TDHS, about 42 percent of children are stunted, 16 percent are underweight and 5 percent are wasted.[43] Different efforts have been adopted in Tanzania to improve children nutrition status. Within a one-year interval from 2010 and 2011, significant reduction in malnutrition observed. In 2011 according to World Health Organization (WHO) estimates on child malnutrition in Tanzania, children aged <5 years stunted was 34.8% in 2011; underweight was 13.6% in 2011; wasted was 6.6% in 2011 and overweight was 5.5% in 2010.[62] Some regions in Tanzania like Iringa, Mbeya and Rukwa are among the five regions with the highest stunting and are all areas with high food production.[61] The case in Tanzania, is inconsistent with the common assumption that increasing agriculture and food production will automatically lead to improvements in nutrition.

Neonatal and under-five mortality 2030

Reducing the number of children dying before their fifth birthday has been targeted in the Sustainable Development Goals under the health related goals. Tanzania has made an improvement in attaining the reduction of child mortality [63] however, basing on the Sustainable Development Goals, the country should further reduce in exact numbers the neonatal and under-five mortality rates by 2030.[64]

Sustainable Development Goals

Sustainable development goals have been developed as a new development agenda after the expiration of the Millennium Development Goals in 2015. The third sustainable development goal aims to enhance healthy lives and promote wellbeing for all at all ages.[64]

SDG 3, target 3.2

The health related Sustainable Development Goal 3, target 3.2 targets a reduction of neonatal mortality to 12 per 1000 live births and under five mortality rate to 25 per 1000 live births by 2030.[64] The world under five mortality rate has declined from 90 in 1990 to 46 in 2013.[65] In Tanzania, the U5MR has declined from 167 in 1990 to 52 in 2013.[66] The country ranks the 48 in the world in 2013 in under five mortality out of 194 countries.[67] Figure 1 shows a comparison of under five mortality rate between the World and Tanzania with data from State of the World's Children 2015 Report[65] and WHO,Global Health Observatory Data Repository.[67] Figure 2 shows a comparison of Neonatal Mortality rates between the World and Tanzania with data from UNICEF 2013 Child Mortality Report [68]

A comparison of Under5 mortality between Tanzania and the world
World vs Tanzania Neonatal Mortality rate

Occupational Health

Tanzania is a United Republic of Former Tanganyika (currently referred to Tanganyika mainland) and Zanzibar. The estimated population has dramatically increased from 12.3 to 44.9 million people from 1967 to 2012 respectively (Figure 1. below),.[69] The current working group (15– 64 years of age) of is estimated to be 52.2%. The National economy still depend mostly on agriculture that holds up to 40% of Gross Domestic Products (GDP).[70] Agriculture sector employs 76.5% of workforce in the Country; Industry sector (4.3%); and services (19.2%).[71]

Figure 1:Tanzania population growth since 1967- 2012

The figure shows the population growth trends for Tanzania from 1967 to 2012

Occupational Health in Tanzania perspective

The country had been operating under Factories Ordinances Cap. 297 of 1950 that provided for occupational health and safety standards in the country. Through various sector reform programmes, The National established Occupational Health and Safety Authority under The Executive Agency Act No. 30 of 1997 which become officially operational late 2001.[72] Moreover, in 2003 the Occupational Health and Safety Act No. 5 was enacted giving the authority mandatory objectives of providing the safety, health and welfare of persons at work in factories and other places of work; to provide for the protection of persons other than persons at work against hazards to health and safety arising out of or in connection with activities of persons at work.[73]

Other Country initiatives the country has gone through includes incorporation of Occupational Health and safety matters in other Principal legislation such as The Tropical Pesticides Research Institute Act of 1979; The Pharmaceuticals and Poison Act of 1978; The Atomic Energy Act of 2003, The Industrial and Consumer Chemicals Act of 1985;[74] The Mining Act of 2010 and Employment and labour relation Act No.6 of 2004 with subsequent establishment of Labour Court (being part of The High Court of Tanzania).

In 2008 another important step was made; The establishment of Workers' Compensation Fund through Workers Compensation Act No. 20 of 2008 [75] with objectives of providing for compensation to employees for disablement of death caused by or result from injuries or diseases sustained or contracted in the course of employment; to establish Fund for administration and regulation of workers compensation and to provide for related matter.

The International Labour Organization (ILO), estimates that more than 2.3 million people die of work-related accidents and diseases every year and 317 million accidents annually occur due to workplace hazards. The figures further explain that out of 2.34 million occupational fatalities every year; only 321,000 are due to accidents, the remaining 2.02 million deaths are caused by various types of work-related diseases, which correspond to a daily average between 5,500 up to 6,000 deaths.[76]

Occupational injuries

Every individual worker needs good working environment that is safe and free from any kind of life - threatening hazards. This may be possible where most if not all health risks are identified at workplace and correct measures are put in place and adhered by all workers around. Mining sector is fast growing in a country and significant number of workers both in conventional and small scale mining are employed. The sector contributes up to 40% of country's export[77] and it was estimated to contribute up to 7.7% of national GDP by end of 2015.

Status of occupational accidents and injuries varies considerably between different sources. It is estimated that in mining/quarry, the injury rate is 17 per 1,000 workers whereas Industry sector is responsible for 10.1% of total occupational accidents, 9.6% of fatalities, 12.2% of partial disabilities and about 7.4% of temporary disability and the injury rate is 9.9 per 1,000 workers.[78]

Report from National Audit office (NAO) showed that construction/building industry had highest Fatality rate of 23.7% followed by Transport and mining/quarrying that had 20.6% and 20.5 respectively (table 1 below).[79] Injuries in transport sector is another life-threatening risk that continues to claim lives of people especially motorcyclist and public transport (buses). however the major challenge in these information is validity and reliability as the reporting and data keeping system in Tanzania is not well coordinated.

Table 1: Fatality Rate sectorwise

Sector Total employees Number of Fatal Injuries Fatality rate (%)
Agriculture, forestry, Fishing 13,890,054 16 0.12
Mining and quarrying 29,223 6 20.53
Commerce and distribution 2,486,818 12 0.48
Manufacturing 245,449 28 11.41
Construction/building 151,690 36 23.73
Transport 111,671 23 20.61
Total 16,914,805 121

Source: NAO report- Performance Audit Report on the Management of Occupational Health and Safety in Tanzania, 2013.

The presented information may be challenged by several other factors as reporting system is not well functional. There were a total of 6,599 registered workplaces equivalent to 24% of eligible workplaces. This challenges is a challenge to The Authority dealing with Occupational safety and Health in Tanzania. Accelerated development as a result of new large discoveries and investments in Oil, gas and Uranium and expected spill - over effects calls for serious investments in this areas as more workers will be involved and exposure to occupational hazards will need serious interventions.

See also

References

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  66. ↑
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  72. ↑ OSHA. "Occupational Ssafety and Health Authority- Tanzania: Background". OSHA-TANZANIA.
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