THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in...

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THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH AND SOCIAL WELFARE May, 2007 PRIMARY HEALTH SERVICES DEVELOPMENT PROGRAMME- MMAM 2007 – 2017

Transcript of THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in...

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THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

May, 2007

PRIMARY HEALTH SERVICES DEVELOPMENT PROGRAMME- MMAM

2007 – 2017

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TABLE OF CONTENTS TABLE OF CONTENTS ....................................................................................................... ii ACRONYMS............................................................................................................................v EXECUTIVE SUMMARY ................................................................................................. viii 1.0 BACKGROUND INFORMATION .............................................................................1 1.1 Introduction....................................................................................................................1 1.2 Geographical Features...................................................................................................1 1.3 Administrative Structure .............................................................................................1 1.4 Population characteristics .............................................................................................2 1.5 Socio economic information ..........................................................................................2 1.6 Health Status ..................................................................................................................3 1.7 Status of Primary Health Care Services ......................................................................3 2.0 POLICY CONTEXT .....................................................................................................4 2.1 Vision 2025......................................................................................................................4 2.2 Millennium Development Goals ...................................................................................5 2.3 National Strategy for Growth and Reduction of Poverty ..........................................5 2.4 National Health Policy...................................................................................................5 2.5 Health Sector Strategic Plan .........................................................................................6 2.6 The Public Service Reform ...........................................................................................6 2.7 Health Sector Reforms ..................................................................................................6 2.8 Local Government Reform Policy Paper.....................................................................7 2.9 CCM Election Manifesto 2005......................................................................................7 3.0 THE PRIMARY HEALTH SERVICE DEVELOPMENT PROGRAMME ..........8 3.1 The Programme concept and rationale........................................................................8 3.2 Objectives of the programme........................................................................................8 3.2.1 Overall objective ..........................................................................................................8 3.2.2 Specific Objectives ........................................................................................................8 3.3 Programme Components...............................................................................................9 4.0 SITUATION ANALYSIS OF COMPONENTS........................................................10 4.1 Human Resources for Health (HRH).........................................................................10 4.2 District Health Services ...............................................................................................13 4.3 Maternal, Newborn and Child Health .......................................................................26 4.4 The National AIDS Control Programme...................................................................29 4.5 Malaria..........................................................................................................................31 4.6 Tuberculosis and Leprosy ...........................................................................................32 4.7 Health Promotion and Education...............................................................................34 4.8 Nutrition........................................................................................................................35 4.9 Public Private Partnership..........................................................................................35 4.10 Traditional and Alternative Medicine. ......................................................................36 4.11 Non Communicable Diseases ......................................................................................38 4.12. Neglected Tropical Diseases. .......................................................................................39 4.14. Advocacy.......................................................................................................................40 4.15.1 Ministry of Health & Social Welfare ...................................................................41

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4.15.2 PMO-RALG. ..........................................................................................................42 4.15.3 Regional Level ........................................................................................................42 4.15.4 Local Government Level. ......................................................................................42 4.15.5 Ward Level .............................................................................................................42 4.15.6 Village Level. ..........................................................................................................43 4.15.7 Responsibilities of Council Health Services Board & Health Facility Com. ....43 4.15.8 Council Health Services Board.............................................................................43 4.15.9 Health Facility Committees...................................................................................43 4.16 . Health Care Financing ................................................................................................45 4.17. Monitoring and Evaluation.........................................................................................46 5.0 COMPONENT OBJECTIVES AND STRATEGIES. ............................................47 5.1 Human Resources for Health......................................................................................47 5.1.1 Objectives.....................................................................................................................47 5.1.2 Strategies.......................................................................................................................47 5.2 District Health Services:..............................................................................................47 5.3 Maternal , Newborn and Child Health ......................................................................49 5.3.1 Objectives......................................................................................................................49 5.3.2 Strategies.......................................................................................................................49 5.4 Malaria..........................................................................................................................49 5.4.1 Objectives; ...................................................................................................................49 5.4.2 Strategies......................................................................................................................49 5.6 Tuberculosis and Leprosy ...........................................................................................50 5.6.1 Objectives......................................................................................................................50 5.6.2 Strategies.......................................................................................................................50 5.7 Neglected Tropical Diseases ........................................................................................51 5.7.1 Objectives.......................................................................................................................51 5.7.2 Strategies........................................................................................................................51 5.8 Non Communicable Diseases ......................................................................................52 5.8.1 Objectives................................................................................................................52 5.8.2 Strategies.................................................................................................................52 5.9 Environmental Health and Sanitation .......................................................................52 5.9.1 Objectives......................................................................................................................52 5.9.2 Strategies.......................................................................................................................52 5.10 Health Promotion and Education...............................................................................52 5.10.1 Objectives................................................................................................................52 5.10.2 Strategies.................................................................................................................52 5.11 Nutrition........................................................................................................................53 5.11.1 Objectives.....................................................................................................................53 5.11.2 Strategies......................................................................................................................53 5.12 Traditional and Alternative Medicine .......................................................................53 5.12.1 Objectives.....................................................................................................................53 5.12.2 Strategies......................................................................................................................53 5.13 Public private partnership ..........................................................................................54 5.13.1 Objectives.....................................................................................................................54 5.13.2 Strategies......................................................................................................................54

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5.14. Advocacy for PHSDP....................................................................................................54 5.14.1 Objectives: ..............................................................................................................54 5.14.2 Strategies: ....................................................................................................................54 5.15 Institutional Arrangement. .........................................................................................54 5.15.1 Objectives: ...................................................................................................................54 5.15.2 Strategies.................................................................................................................54 5.16 Health Care Financing ................................................................................................54 5.16.1 Objectives................................................................................................................54 5.16.2 Strategies: ...............................................................................................................55 5.17 Programme Monitoring and Evaluation .....................................................................55 5.17.1 Objectives................................................................................................................55 5.17.2 Strategies.................................................................................................................55 6.0 LOGICAL FRAMEWORK........................................................................................56 6.1 Annual Activity Targets ..............................................................................................56 6.2 Financial Outlays .........................................................................................................56 ANNEX 1: ANNUAL ACTIVITY TARGETS ...............................................................58 ANNEX 2: FINANCIAL OUTLAY..............................................................................106 ANNEX 3: IMPLEMENTATION PLAN FOR PHSDP.............................................107

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ACRONYMS AIDS Acquired Immuno – Deficiency Syndrome ART Anti Retroviral Therapy ASRH Adolescent Sexual Reproductive Health BOD Bearden of Disease BOD Burden of Disease CCHP Comprehensive Council Health Plans CHF Community Health Funds CHMT Council Health Management Teams CHR Child Mortality Rates CHSB Council Health Services Board CMO Chief Medical Officer CPR Contraceptive Prevalence Rate DHIR District Health Infrastructure Rehabilitation DHS Demographic and Health Surveys DHS Demographic Health Survey DIFID Department for International Development, UK DOT Direct Observed Treatment DUHP Dar es Salaam Urban Health Project EHIP Essential Health Interventions Package EmOC Emergency Obstetric Care ENA Essential Nutrition Actions ENT Ear, Nose and Throat EPI Extended Programme on Immunization EPZ Export Promotion Zone ERP Economic Recovery Programme ESAF Economic Structural Adjustment Facility ESAP Economic and Social Action Programme ETAT Emergency Triage Assessment and Treatment FANC Focused Ante-natal care FP Family Planning FPMS Financial Planning and Management System GDP Gross Domestic Product GNP Gross National Product GOT Government of Tanzania HBS Household Budget Survey HC Health Centre HE Health Education HIS Health Information System

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HIV Human Immuno deficiency Virus HMIS Health Management Information System HRD Human Resources Development HSR Health Sector Reforms ICB International Competitive Bidding IDA International Development Agency (World Bank) IEC Information Education and Communication ILO International Labour Organization IMCI Integrated Management of Childhood Illnesses IMR Infant Mortality Rates IPPF International Planned Parenthood Federation IRP Integrated Roads Programme IRTAP Industrial Restructuring and Trade Adjustment Programme JAS Joint Assistance Strategy JRF Joint Rehabilitation Fund KMC Kangaroo Mother Care LC Local Competition LGA Local Government Authority MCH Maternal and Child Health MCHA Maternal and Child Health Aides MDG Millennium Development Goals MIS Management Information System MKUKUTA Mkakati wa Kukuza Uchumi na Kupunguza Umaskini

Tanzania (NSGRP) MMAM Mpango wa Maendeleo wa Afya ya Msingi (PHSDP) MNH Muhimbili National Hospital MNR Maternal Mortality Rates MOF Ministry of Finance MOHSW Ministry of Health and Social Welfare MPDE Methodology for Project Design and Evaluation MRTH Muhimbili Research and Teaching Hospital MUCHS Muhimbili University College of Health Sciences NACP National AIDS Control Programme NDP National Drug Policy NGO Non Government Organization NIMR National Institute of Medical Research NORAD Norwegian Aid Agency NSGRP National Programme for Economic Growth and Poverty

Reduction (MKUKUTA) NTDs Neglected Tropical Diseases OBYS Obstetric and Gynaecology OPD Out patients Department

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PAC Post Abortal Care PCR Project Completion Report PER Public Expenditure Review PFP Policy Framework Paper PHC Primary Health Care PHN Public Health Nurse PHSDP Primary Health Services Development Programme PIU Project Implementation Unit PMO-RALG Prime Minister’s Office, Regional Administration and

Local Government PMTC Prevention of Material to Child Transmission of HIV Virus POA Programme of Work PPB Patients per Bed RHMT Regional Health Management Teams RMAs Rural Medical Aides RPFB Rolling Plan and Forward Budget RS Regional Secretariat STI Sexual Transmitted Infections TA Technical Assistance TACAIDS Tanzania Commission on AIDS TAF Technical Assistance Fund TB Tuberculosis TBA Traditional Birth Attendant TFR Total Fertility Rate TRCHS Tanzania Reproductive and Child Health Survey TRHS Three Region Health Study TSH Tanzanian Shillings

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EXECUTIVE SUMMARY  

The Primary Health Service Development Programme is one of the major Government undertakings in the Social Services Sector. This is in response to long term Government commitment of improvement of the Social and economic well being of the people through provision of quality social services health being one of them. Others are education and water. Although the government’s commitment has always been provision of fair, equitable and quality health services, this commitment has never borne the desired outcome. This is due to the fact that the burden of diseases is still high and the coverage of the services is inadequate. Generally, the quality of health services in Tanzania, despite remarkable improvements over the years since the advent of health sector reforms in the early 1990s, is still unsatisfactory. The performance of the health sector has been negatively affected by limited resources which have led to an unsatisfactory quality of health care provision at all levels. Under funding of the health sector has undermined the health infrastructure across the country. The inputs to the sector in terms of equipment, supplies, transport and communication remain insufficient. The MoHSW staffing levels versus existing staff shows an enormous HRH shortage across all main cadres. It is worse among Clinicians, Nurses, Pharmaceutical Technicians, Laboratory Technicians, Radiographers, Therapists, Health Officers and Health Administration cadres. According to the MoHSW staffing level (1999) 46,868 qualified health professionals in the public health facilities are required while the available technical staffs are 15,060 which equals to 32.1% of the requirement, this reveal a shortage of 31,808 equal to 67.9%. This analysis reflects the whole system from the lower level up to the higher level of the health services. The Social Welfare services are also affected whereby, the number of technical staff required is 816 while the actual strength is 269 and the deficit is 547, which indicate 67% of the requirement.

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The country has 126 training institutions of which government owns 62 and 64 are owned by the private sector and faith based organizations. There are also 6 medical universities 5 of which are privately owned. For the past nine years the output from medical schools is 23,536 including all cadres in health from certificate to postgraduate studies. This is far below the required output that would bridge the existing human resources shortage. The Ministry of Health and Social Welfare has established 8 Zonal Training Centres (ZTC) to facilitate the update of health workforce skills particularly at the district level. Given the changing and expanding roles of health workers it is necessary to ensure that in service training/continued professional development is essential interventions to build their competence. As regards maternal health, maternal mortality rate is 578 deaths per 100,000 lives births. Over 80% of the maternal deaths are due to direct causes that includes obstetric, haemorrhages, obstructed labour, pregnancy induced hypertension, sepsis and abortion complications. The majority of maternal deaths can be prevented if pregnant women can be assured of access to skilled attendance at childbirth and emergency obstetric care when pregnancy related complications arise.

According to (TDHS 2004), 94% of pregnant women attend antenatal care at least once. However, the quality of antenatal care provided is inadequate. Regardless of high ANC attendance, only 47% of births occur at health facilities. Of all deliveries occurring in health facilities, only 46% are attended by skilled attendants. Major barriers to access delivery health services include long distance to a health facility, lack of transport and unfriendly services. The high rates of home deliveries are also attributed to poor geographical access to health facility, lack of functioning referral system, inadequate capacity at health facilities in terms of space, skilled attendants, equipments and other socio-cultural aspects surrounding the pregnant women. Additional factors include gender inequalities in decision-making and access to resources at household level. Furthermore, the referral system has serious challenges including limited number of ambulances; unreliable logistics and communication system; and low community based facilitated referral system.

HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have passed away of AIDS since 1983. Since the outbreak of the first case of HIV and AIDS the

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prevalence rate has been fluctuating above 12% in 1990s. With interventions prevalence rate has decreased in all age groups to less than 7% to date. Testing and Counselling is an entry point for care, treatment and support for people living with HIV/AIDS (PLHA). Services have been established in 1,027 sites (3 VCT sites in each district). Community Home Based Care (CHBC) services have been established in more than 70 districts. A total of 1,400 HBC providers have been trained at the health centres and dispensaries and more than 200 HBC providers have been trained at the community level. STI services have now been established in all 21 regions of Tanzania Mainland, covering all public hospitals, health centres, 60% of dispensaries and some private owned facilities. Prevention of Mother to Child services have been expanded to all regional hospitals and other 145 hospitals including district and faith based owned hospitals, 182 health centres and 332 dispensaries. Already 255,913 pregnant women have been reached with PMTCT services.

The Government with support from partners intends to scale up HIV and AIDS prevention, care and treatment interventions to reduce prevalence by 50% from the current rate of 7% and provide 800,000 AIDS patients on ART.

The number of clinical malaria cases per year is estimated to be 17 – 20 million resulting in approximately 100,000 deaths. The population groups most vulnerable to malaria are children under five years and pregnant women, due to their particular immunity status. The current estimated infant mortality and under five year mortality rates are 68 and 112 per 1,000 live births respectively (2004-05 TDHS). Maternal mortality is estimated at 578 deaths per 100,000 live births. Life expectancy at birth is 45 years. It has been estimated that malaria contributes to about 36% of all deaths in children under five years of age (IHRDC-DSS, 2005).

Tuberculosis continues to be among the major public health problems in the country accounting for 7% of the burden of disease in the country up from 5% in 1999. The number of tuberculosis cases notified in country has steadily increased from 11,753 in 1983 to over 64,000 in 2004, which is almost six-fold increase. Data from AMMP shows that TB is the third cause of deaths among adults after malaria and HIV/AIDS.

Majority of TB cases are young adults aged 15-45 years, the same age group affected by HIV/AIDS. Nearly two thirds of all TB cases notified are males.

The number of registered leprosy cases notified annually has decreased from over 35,000 cases in 1983 to about 4,500 in the year 2004. About 8% of the annual

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notified cases are children under 15 years of age and 10% have permanent disability according to WHO classification. The number of newly notified cases has not significantly changed in the last one decade despite intensification of leprosy elimination campaigns. The number of registered leprosy in Tanzania in the year 2004 was 1.4 per 10,000 populations which is still above the World Health Organisation (WHO) target of 1 case per 10,000 populations. The Tanzanian community still faces diseases such as Onchocerciasis, Lymphatic Filariasis, Helminthiasis, Schistosomiasis and Trachoma. Such diseases need to be controlled by adopting integrated disease management system that includes; public health interventions and mass treatment.

Health education and promotion is a means of increasing individual and community participation in health action. Its implementation involves health education, advocacy, social and community mobilization, information, education and communication, mediation and lobbying. The aim is to empower the community for health improvement.

In order to address the identified state of affair, the Government has developed the Primary Health Service Development Programme (PHSDP).

The Programme essentially aims at promoting access to basic health care for all as well as empowering and involving the community in the provision of health services. The programme has a time duration of 10 years from 2007-2017. It is estimated to cost a total of Tshs. 9.66 trillion for the implementation of the 17 components identified and prioritized. The components are; human resources, district health services maternal, Newborn and child health, malaria, HIV and AIDS, tuberculosis and leprosy, non communicable diseases and health promotion and education. Others are nutrition, traditional medicines, neglected tropical diseases public private partnership, advocacy, Institutional arrangement, health care financing and monitoring and evaluation. Human resource for health is the first priority of PHSDP. PHSDP seeks to address the human resources crisis by increasing output both in terms of quantity and quality. The thrust is to have in place the right number of qualified, skill mix and motivated staff in right place at the right time. Expansion of training intake, recruitment and creating an enabling environment that will facilitate retention of health workers are some of the measures to be undertaken. This will demand providing attractive incentive package targeting mainly those working in hard to reach difficult areas. Increase, expansion and rehabilitation of health training institutions will be prioritized. Equally important will be provision of teaching

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equipments and materials. Overall objective is to employ and deploy skilled staff to fill the current gap of 68 percent of required human resources. District health service is the second priority component. Under this component, PHSDP will focus on construction of 3088 dispensaries, 19 district hospitals, 95 maternity waiting homes and 2,074 health centres. Furthermore 250 dispensaries, 120 health centres and 54 district hospitals will be rehabilitated. Services provided by health centres and district hospitals focusing on maternal health will be improved through strengthening 2555 health centres and 62 district hospitals. This will involve construction of emergency Obstetric Care (EmOC) complete with necessary medical equipment, plant and furniture. A total of 128 training institutions will also be rehabilitated, constructed and upgraded. Other major undertaking will include provision of medicines, medical supplies strengthening out reach services through provision of 2574 ambulances, 140 supervision vehicles and 114 mobile clinics. Communication system to all 114 districts and referral system will be improved and strengthened. Under maternal newborn and child health, HSDP aims at contributing to the reduction of maternal and under five mortality from 578 and 175 per 100,000 live births and 112 to 45 per 1000 live births respectively. HSDP also aims at increasing coverage of births attended b y skilled attendant up to 88 percent by 2017 from the current level of 46. To achieve this, the programme focuses on building capacities of service providers at hospitals, health centres and dispensaries through training in advanced and basic lifesaving skills essential new born care. Family planning Essential nutrition action, IMCI immunization and data management will be emphasised. Training will also be provided to 15,000 youth peer educations and immunization outreach services will be provided to 8000 villages. In addition Kanga Vouchers will be provided to 14 million women at delivery. Malaria is the fourth priority component in the HSDP. The programme seeks to reduce the burden of Malaria by 80 percent by the end of the programme period. Sensitization of community on control and prevention of Malaria at all levels, promoting the use of ITNs and introduction of indoor residual spraying are some of the measures to be undertaken. Under HIV and AIDS, HSDP will increase and strengthen services on care and treatment of people living with HIV and AIDS. The programme will also increase access of services for the prevention of mother to child transmission in all health facilities. Provision of voluntary counselling, home based care services

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and increase the number of HIV and AIDS patients on ARV’s from the current level of 70,000 to 800,000 will be prioritized. Another component included in the HSDP is tuberculosis and leprosy control. The objective is to reduce prevalence and death rates associated with the disease by 50 percent by the end of 2017. The programme also aims at elimination of leprosy as a pubic health problem in the country. Control and prevention of non communicable diseases will also be prioritized. Emphasis will be in promotion of acceptable lifestyles and training of service providers. Furthermore the programme will strengthen and improve environmental health sanitation and hygiene services. Focus will be a formulation and enforcement of environmental health By-laws in all villages and promotion of environmental health and sanitation services. Health promotion and education which is one of the main strategies of promoting health seeking behaviour of the community will be given priority. Capacity building of the communities and individuals to get involved in health promotion and education activities at all levels will be enhanced. Under nutrition component, priority will be on building capacity for nutrition intervention at district and community levels. Emphasis will be on recruitment and deployment of staff who will provide technical support and ensure coordination of nutrition among health programmes and create linkages with other sectors. Public private partnership will be also being promoted. The objective is to sustain and strengthen the partnership. Under Traditional and Alternative Medicine, focus will be on promotion and formulation of value added traditional medicine products and establishment and strengthening of registration of traditional health practitioners. Neglected tropical diseases will also be prioritised. The diseases will be mapped to identify distribution. Mass drug administration rounds will be undertaken in all endemic districts. The implementation of PHSDP will need the participation and evolvement of various stakeholders from national to the community levels. Their participation and involvement will depend on how informed and their appreciation of the programme. This can be achieved through advocacy. Advocacy is thus one of the components within the programme. This is a key component. It will facilitate

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mobilization and from various sources. The more important is the mobilization of the community to get fully involved and motivated to participate in the implementation of the programme. Modalities for coordination and supervision of the implementation of HSDP have been elaborated under Institutional framework. The various roles and responsibilities of the key actors at each level have been identified. At the Central level the coordination roles rests with Ministry of Health and Social Welfare in collaboration with the Prime Ministers Office, Regional Administration and Local Government. Specifically the Ministry of Health and Social Welfare will be responsible for provision of policy guidelines, resource mobilization and capacity building of the Regional Secretariat PMO-RALG on the other hand will be responsible for supervising the implementation of the Programme at Local Government Authorities (LGAs) level. At the regional level, the Region Secretariat will provide technical support to LGAs including ensuring incorporating the programme in the CCHPs. The Local Government Authorities will be responsible for management and implementation of the programme. Their responsibilities will also include provision of technical support to lower level mainly wards and villages. Other levels are Wards and Villages. The Ward Development Committee and Village Government will be responsible for coordinating and supervising the various activities to be carried out at these levels. Mobilization of the community for their active participation and involvement will be the responsibility of these levels. In addition, Council Health Service Boards and Health Facility Committees will play a vital role in the implementation of PHSDP. The implementation of PHSDP will be financed through Government budget and from off-budget sources. The off-budget sources include complementary financing schemes. These will include user fees, Drug Resolving Fund, National Health Insurance Fund and Community Health Fund. These financing options have the potential of raising Tshs. 15.4 billion per annum to finance this programme. The community on the other hand is estimated to contribute about 20 percent of the overall programme budget in form of labour and material input. Monitoring and evaluation of the programme is another important component of the programme. There will be a continuous and regular monitoring of the programme. There will also be a mid-term and end-term evaluation of the programme.   

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1.0 BACKGROUND INFORMATION

1.1 Introduction Since independence in 1961, the Government has consistently focused its development strategies on combating ignorance, diseases, and poverty. The investment in primary health services is recognised as a potential tool in fighting diseases at the same time improving the quality of lives of the majority of people. Before outlining the challenges facing the primary health services perhaps it is important to understand the general information in which primary health services are placed. The information is on country’s geographical features, administrative structures, current population characteristics, socioeconomic situation, health status, organization and management of health services, and the present status of primary health care services.

1.2 Geographical Features The United Republic of Tanzania is a union between Tanganyika and Zanzibar, which was formed in April 1964. It lies between the latitudes 1oS and 120S and longitudes 300 East and 400 East. It is the largest country in East Africa, occupying and area of about 945,087 sq. km, and has common boarder with 8 neighbouring countries: Kenya and Uganda to the North: Rwanda, Burundi and DEmOCratic Republic of Congo to the west, Zambia, Malawi and Mozambique to the South. There are two seasons of rainfall – long rains from March to May and short rains from November to January. The vast geographical spread of the country poses great challenges to physical accessibility of health facilities, at the same time the rain seasons influences the pattern of diseases.

1.3 Administrative Structure Tanzania Mainland is divided into 21 administrative regions and 114 districts with 133 Councils. Each district is divided into 4 – 5 divisions, which in turn are composed of 3 – 4 wards. Every 5 – 7 villages form a ward. There are a total of about 10,342 villages. Management of government activities within districts are through Local Government Authorities (LGAs). The Council is the most important administrative and implementation authority for public services. For this reason, the Ministry of Health and Social Welfare is currently working with the Prime Minister’s Office Regional Administration and Local Government to strengthen the LGAs to deliver quality health services in line with established national and international standards. Local Government

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Authorities at district level will therefore play a key role in the implementation of this programme.

1.4 Population characteristics The total population of Mainland Tanzania is projected to be 38,710,723 for the year 2007. The population is growing at the rate of 2.9. Total Fertility Rate (TFR) stands at 6.3 per woman indicating a slight decline as compared to 1988(6.5) population Census. However, the rate of population growth differs across the 21 regions of Mainland Tanzania. Population composition is 48.9 percent for males and 51.1 percent for females. The national population density stands at 38 people per square kilometre; however, this varies considerably from region to region. The increasing population exerts a massive pressure to primary health services since they are not stocked and equipped adequately to meet the demands of the increasing population.

1.5 Socio economic information GPD per capita is at 360. The real GDP is estimated to grow at 5.8 per annum. The slowdown in real GDP growth rate during 2006 was attributed to acute drought, energy shortages, and hiked oil prices towards the end of 2005. Low level of GDP has direct effect to development and operations of the health services development. Health was identified as one of the priority sectors within the first Poverty Reduction Strategy (PRS) and was expected to benefit from increases in both the absolute level of government funding, and in its share of the budget. The share was highest in the 2001/02 when it reached 11 percent. There was a drop in the health sector’s share during the financial year 2002/03 and 2003/04 such that by 2003/04 the share had dropped to 9.7 percent. However, there seems to be an increase to 10.1 percent in the FY 2004/05. This is encouraging, although it should be noted that it still falls short of the share achieved in the earlier years of the PRS. It also falls short of the 15 percent of Abuja commitment. More important, the allocation is not adequate to meet the increasing demands of primary health care functional accessibility. The programme therefore proposes to phase implementation of different activities in the context of resource constraints. This is limiting to achieving increased coverage of health services functional and geographical accessibility.

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1.6 Health Status The Burden of Disease (BOD) is high. Malaria remains to be a major cause of morbidity and mortality both in rural and urban areas. It ranks number one in inpatient and outpatient statistics. It is also a major cause of death for children age below five years and inflicts a huge burden due to anaemia, especially in pregnant women. In recent years the pattern of malaria has dramatically changed expanding into areas previously known to be malaria free. Also there has been an increase in number of cases and deaths due to HIV/AIDS and tuberculosis. The three diseases form a major threat to the health systems in Tanzania. Health outcome indicator shows that Life expectancy at birth for Tanzanians is on average of 51 years (2002 census) compared with 50 years (1988 census), probably attributed to effects of the HIV/AIDS. Under Five Child mortality is on declining trend form 147 per 1000 in 1999 to 112 per 1000 in 2005 and Infant mortality rate has declined from 99 per 1000 to 68 respectively. Although promising the level is unacceptable if compared to developed countries. Maternal Mortality Rate has remained high. In 1996, maternal mortality was 529 while in 2005 was 578 per 100,000 live births. With regard to children nutritional status has greatly improved since 1999 to 2005. Stunting has decreased from 44 percent to 38 percent while wasting from 5 percent to 3 percent and underweight from 29 percent to 22 percent. With increased efforts to strengthen primary health services presented in this proposal there is more room to make improvement.

1.7 Status of Primary Health Care Services Primary health Care services form the basement of the pyramidal structure of health care services. It is made of a number of dispensaries, health centres and District hospital at the district level. Currently the health facilities for both public and private include 4,679 dispensaries, 481 health centres and 219 hospitals distributed throughout the country. The dispensaries and health centres that are at a centre of primary health care facilities were planned to serve an average population of 10,000 and 50,000 respectively. However, with increasing population and slow pace/stagnation of construction primary health facilities, the average population served by each dispensary and health centres is more than the planned population, overstretching the effective functioning of the current primary health care

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facilities. The problem is compounded with shortage of staff, inadequate medical equipment and other supplies. The geographical accessibility of the current primary health facilities is reported to be at about 90% of people living with five kilometres. Nevertheless, there is great variation among districts. Besides, land terrain and lack of reliable transport poses a great danger to expecting mothers and very sick patients to access health services when they need them. These factors influence accessibility of primary health services.

2.0 POLICY CONTEXT The government has developed a number of enabling policies and environment as an effort to strengthen the health services in the country. Enabling policies are both national and international commitments like National Vision 2025, National Strategy for Growth and Reduction of Poverty (NSGRP), Millennium Development Goals and National Health Policy, Health Sector Strategic Plan, and Policy Paper on Local Government Reform.

2.1 Vision 2025 In the Tanzania Development Vision 2025 the main objective is achievement of high quality livelihood for all Tanzanians. This is expected to be attained through strategies, which will ensure realization of the following health services goals: - (i) Access to quality primary health care for all; (ii) Access to quality reproductive health service for all individuals of

appropriate ages; (iii) Reduction in infant and maternal mortality rates by three quarters

of current levels; (iv) Universal access to clean and safe water; (v) Life expectancy comparable to the level attained by typical

middle-income countries; (vi) Food self sufficiency and food security; (vii) Gender equality and empowerment of women in all health

parameters; (viii) Encourage the participation of community in the delivery of health

services. In line with Government Development Vision 2025 goals, the Ministry of Health and Social Welfare is expected to contribute towards the

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improvement of health status and life expectancy of the people of Tanzania. This can partly be achieved through public health interventions and primary health services.

2.2 Millennium Development Goals The fact that the government has its own commitments, also it has international commitments like Millennium Development Goals. Under these commitments the government is required to reduce child mortality by two-thirds, and improve maternal health by reducing MMR by three-quarters from 1990 to 2015. Also, to combat HIV/AIDS, Malaria and other diseases by controlling them by 2015 and began to reverse the spread of HIV/AIDS.

2.3 National Strategy for Growth and Reduction of Poverty The health sector is challenged to meet the health related Millennium Development Goals. NSGRP places these goals within cluster II which addresses improvement of the quality of life and social well being. The Ministry of Health and Social Welfare will use a greater proportion of the health budget to target cost effective interventions such as immunization of children under 3 years of age, Reproductive and Child Health including Family Planning and control of Malaria, HIV & AIDS, TB and leprosy. These interventions are on going and will be accelerated through the implementation of Primary Health Service Delivery Programme (PHSDP).

The majority of the poor and specifically the rural poor suffer from the above and other preventable conditions. The Ministry will continue to advocate for an increase in resource allocation to address cost effective interventions, while at the same time join hands with other stakeholders, the communities and development partners to reorient the services to be more responsive to the needs of the population, and specifically targeting the indigent and vulnerable groups.

2.4 National Health Policy The National Health Policy aims at implementing national and international commitments. These are summarized through policy vision, mission, objectives and strategies. The Health Policy vision is to have a healthy community, which will contribute effectively to an individual development and country as a whole. The mission is to facilitate the provision of basic health services, which are proportional, equitable, quality, affordable, sustainable and gender sensitive. Both the vision and

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mission of the health policy supports the attainment of the PHSDP objectives and targets.

2.5 Health Sector Strategic Plan The Ministry in collaboration with all stakeholders has been providing health services within the framework of Health Sector strategic Plan. The current Strategic Plan will end in June 2008. The next Strategic Plan to be developed will cover a period of 5 years from 2009/10 to 2014/15. The Health Sector Strategic Plan has three components. The components are district health services, secondary and tertiary hospital services and the central support systems. The PHSDP aim at strengthening the district health services component within the Strategic Plan.

2.6 The Public Service Reform The programme aims at transforming the public service into a service that has the capacity, systems and culture for continuous improvements of services. The main issues on which the programme focuses are: Weak capacity of the public services and poor delivery of public services. In order to implement aims of the public reform, each sector is executing sectoral reforms in line with public reform. This includes provision of adequate and skilled .staff in health facilities which is one of the priorities of PHSDP.

2.7 Health Sector Reforms Health sector reform aims at improving the health sector in provision of quality health services for communities. Health sector reforms is a sustainable process of fundamental change in national health policy and institutional arrangement that are evidenced based. The reform has nine strategies as follows: -

• District health services; • Secondary and tertiary level referral hospital services; • Role of the central MOHSW; • Human resource development; • Central support systems; • Health care financing; • Public and private mix; • Donor coordination; • HIV/AIDS.

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However, the above nine strategies have been grouped into three components; namely District health services, Secondary and tertiary health services and central support to central ministries and regions. The PHSDP will be consolidating and strengthening the nine strategies within the Health Sector Reform.

2.8 Local Government Reform Policy Paper The local government reform denotes devolution of powers and establishment of a holistic local government system, to achieve a dEmOCratic and autonomous institution. Within this context primary health services are also managed and administered by Local Government authorities. The PHSDP which aims at strengthening PHC Services will be implemented within the Local Government Reform.

2.9 CCM Election Manifesto 2005

The Health Sector Development Program will facilitate the attainment of commitments and targets proclaimed by the ruling Party, Election Manifesto 2005 in the health sector as follows;

• Reduction of Infant Mortality Rate from 95 to 50 per 1000 live births

by year 2010. • Reduction of under-fives deaths from 154 to 79 per 1000 live births by

year 2010. • Reduction of Maternal Mortality Rate from 529 to 265 per 100,000

live births by year 2010. • Increase coverage of births attended by skilled attendants from 50% to

80% by year 2010. • Strengthen the HIV/AIDS prevention and control initiatives. • Ensure all health facilities are well equipped.

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3.0 THE PRIMARY HEALTH SERVICE DEVELOPMENT PROGRAMME (PHSDP)

3.1 The Programme concept and rationale The aim of policy and government commitments is the delivery of health services to ensure fair, equitable and quality services to the community. Furthermore, the policy aims at empowering communities and involving them in health services provision. Unfortunately fair, equitable and quality services remain to be desired. This is because the burden of diseases is still very high due to continued existence of communicable and non-communicable diseases. As a result, communities are still faced with many cases of mortality and morbidity.

The biggest problem is inadequate coverage of the health system to deal with the health service needs of all people in the country. This state of affair mainly is due to uneven distribution of health services to different communities. The outcome of this, in some areas people need to travel long distance or many hours before reaching the point of health services delivery. This problem is due to poor infrastructure especially in rural areas. Uneven distribution of heath services also contributes to poor quality of services as some of communities are left out of health services participation. Since independence, the government main focus has been to ensure that health services reach all the Tanzanians especially those living in rural areas. However, due to various constraints this objective has not been accomplished in full. In order to ensure that health services reach all the people the government is planning to speed up the process and the focus will be on the district health services where people can easily access services. The overall objective will be to provide accessible quality health services to all Tanzanians by 2017.

3.2 Objectives of the programme

3.2.1 Overall objective To accelerate provision of quality primary health care services to all by 2017.

3.2.2 Specific Objectives • To rehabilitate, upgrade and establish facilities at primary level to

ensure equity and access of quality health care to all Tanzanians

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• To upgrade and establish more training institutions to ensure quality and adequate availability of skilled Human resources for Health.

• To fast track capacity building, upgrading and on job skills development for allied health workers to meet the needs of the primary health facilities.

• To strengthen and maintain human resource database • To provide standardized medical equipment, instruments,

pharmaceuticals and sundries to all primary health facilities to ensure optimal performance

• To ensure that referral system is operational, and where necessary to establish teams of consultants to conduct mobile clinics and outreach services to support health facilities quality health care and minimize unnecessary referrals.

• To increase financial allocation to the sector with a view to attain the Abuja Call of 15% of the annual budget.

3.3 Programme Components The programme has 17 components which will contribute to the attainment of the above objectives. The components are as follows:-

• Human Resources for Health • District Health Services (Infrastructure, Pharmaceuticals and

Supplies, Equipment, Transport, Furniture and Plants) • Maternal, Newborn and Child Health • Malaria • HIV/AIDS • Tuberculosis and Leprosy • Non Communicable • Environmental Health Services • Health Promotion and Education • Nutrition • Traditional Medicines • Neglected Tropical Diseases • Public Private Partnership • Advocacy • Institutional Arrangements • Health Care Financing • Monitoring and Evaluation

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4.0 SITUATION ANALYSIS OF COMPONENTS 4.1 Human Resources for Health (HRH)

Human resources situation has shown a decline of skilled human resources from 67,000 in 1994 to 49,000 in 2001/02. The MoHSW staffing levels versus existing staff shows an enormous shortage of human resource for health across all main cadres. It is worse among Clinicians, Nurses, Pharmaceutical Technicians, Laboratory Technicians, Radiographers, Therapists, Health Officers and Health Administration cadres. According to the MoHSW staffing level (1999) 46,868 qualified health professionals in the public health facilities are required while the available technical staffs are 15,060 which are equal to 32.1% of the requirement. This reveals a shortage of 31,808 equal to 67.9%. The analysis reflects the situation of the human resources for health crisis at all levels.

Other sectors, which complement the Ministry in the provision of health services, are facing the same problem. The situation in the Faith Based Organizations and private sector is becoming worse currently due to the staff movement trends to the public facilities. The Social Welfare services are also affected whereby, the number of technical staff required is 816 while the actual strength is 269 and the deficit is 547, which indicate 67% of the requirement.

The Ministry of Health and Social Welfare is dedicated to ensure equitable, quality and accessible health services. This calls for deliberate effort to formulate new health policies and subsequent plans to facilitate achievement of the desired health services. As a response, the Ministry has developed a Primary Health Services Development Programme (PHSDP), which is focusing on catalyzing improvement in access of health services at all, levels. Among the strategic issues critical to the success of this programme is to have in place the right number of motivated, qualified and skill mix staff in the right place at the right time. This will facilitate the provision of quality and accessible services to meet the health need of all Tanzanians. The need to do the situational analysis of the major strategic issues in human resources is therefore inevitable so as to address existing challenges. These issues are training and development, and management that include recruitment, deployment and retention.

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Training and development Among the most serious HRH challenge facing the health sector is the existing low production capacity both quantitatively and qualitatively. There is also, limited skills, knowledge and competence gap among health workers to cope with fast technological advancement in health. The training and supply of health workers has not kept pace with health sector needs, both quantitatively and qualitatively. The country has 126 training institutions of which government owns 62 and 64 are owned by the private sector and faith based organizations. There are also 6 medical universities 5 of which are privately owned. For the past nine years the output from medical schools is 23,536 including all cadres in health from certificate to postgraduate studies. In-service training (IST) and continuing professional development (CPD) is essential for updating and maintaining health workers skills and knowledge and for assuring quality service provision. IST/CPD systems and practices need to base on the factors such as changing disease patterns and health services demand. Unfortunately, the capacity of the current IST/CPD system to address these issues is limited. In-service training interventions need to be well coordinated. In service training programmes are often done outside the working environment contributing to staff absences and increased workloads for those remaining on site.

The MoHSW has established 8 Zonal Training Centres (ZTC) to facilitate the update of health workforce skills particularly at the district level. Given the changing and expanding roles of health workers, it is also important to ensure that IST/CPD interventions focus on professional and personal as well as medical training and development. The justification to train and develop workers is due to: • The increasing burden of disease as a result of HIV/AIDS and

expanding health worker’s roles and new forms of service provision. • Political commitment to establish health facility in every village which

translate to additional skilled health workers • Presence of tremendous community enthusiasm and expectations for

health improvement • Realization and commitment to address critical HRH shortage in the

Health sector • Increase and maintain the supply and production of human resources,

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• The need to maintain standards and quality Human Resource Management There are multiple players in the management of human resources for health sector. It is a shared responsibility undertaken by MoHSW, Local Government Authorities and the private sector who are employers under the facilitation of POPSM. The Ministry of Finance is the financier. The MoHSW is the technical Ministry responsible for developing policy and guidelines as well as ensuring standards in health care delivery at all levels. Having multiple players in the management of human resource for health has contributed to inefficiency in some practices including development, recruitment, deployment and retention processes. The government has identified HRH as a priority area and is fully committed for its improvement. A number of initiatives are currently being undertaken by the MoHSW to address the HRH crisis. This plan seeks to address the following human resources’ areas; Recruitment and Deployment The health sector has also suffered from under investment in health infrastructures including staff housing, provision of water, basic communication, transport and working tools and materials. The hardships in the most remote areas and hard to reach is a great challenge to retain qualified staff in adequate numbers. MoHSW acknowledges the obligation of ensuring the availability of competent and adequate staff with appropriate skill mix. In assuming this responsibility various initiatives are being implemented. These include special three year recruitment permit from February 2006 to February 2009, substantial increment of HRH wages as per Civil service Circular number 1 of 2006, the emergency hiring initiatives and ongoing efforts to develop HRH strategic plan of 2007 which presents a long term strategy to address the HRH crisis in the country. In addition, the Benjamin William Mkapa Foundation is complementing the Government effort in the recruitment of health workers in remote and hard to reach areas. The Foundation works by providing a three years contract with a special incentive package. Retention The HRH crisis in the health sector is attributed to various related causes, lack of retention strategies being one of them. Socio-economic disparities

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and other work environment challenges have been factors that put off professionals and thereby affecting their retention, particularly in the rural areas. Improving Human Resource Management (HRM) has the purpose of ensuring that staff knows what they are supposed to do, get timely feedback, feel valued and respected, and have opportunities to learn and grow on the job. An incentive package and retention strategy need to be developed that will take into account the need to improve performance and management. The PHSDP seeks to encourage improved retention of health staff particularly in hard to reach districts using innovative retention strategy. Efforts to encourage health workers to accept postings to very remote areas would be explored. The use of attractive differential incentive packages including preferential career development would be advocated.

4.2 District Health Services

Generally, the quality of health services in Tanzania, despite remarkable improvements over the years since the advent of health sector reforms in the early 1990s, is still unsatisfactory. For a long time, the performance of the health sector has been negatively affected by limited resources which have led to an unsatisfactory quality of health care provision at all levels. The reforms are aimed at enhancing the effectiveness and efficiency in the provision of health services in line with the health sector policy of ensuring accessibility to health care services by all Tanzanians.

The total population of Tanzania has almost tripled during 35 years period between 1967 and 2002, when the most recent population census was conducted. Of the total 33,461,849 Tanzanians on Mainland Tanzania, 77 percent were in rural Tanzania while 23 percent were living in urban areas. However, like in any other developing country, there is rapid urbanization with figures showing that the proportion of the population in urban areas increased from 6 percent in 1967 to 23 percent in 2002.

Most of the population in Tanzania is rural and the majority of Local Government Authorities or Councils on Mainland Tanzania (106 out of 133) are classified as rural. Health services in urban areas have tended to be relatively better than those in rural settings. This is attributed to many reasons including unfair allocation of resources.

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Under funding of the health sector has undermined the health infrastructure across the country. The inputs to the sector in terms of equipment supplies, transport and communication remain insufficient. Local Councils, especially rural ones, have benefited from a redistribution of health allocations through a more equitable pro poor Resource Allocation Formula in recurrent funding for health care. Also the set up of capital investment and health infrastructure development funds are steps in the right direction, though certainly not enough to cover deficits. This is most noticeable at primary care and district hospital level, and especially in all aspects of obstetric and surgical care. This special focus on district health services is of particular importance to Tanzania in the context of the government’s policy of decentralization by devolution and the commitment to reaching the goals under MKUKUTA and MDGs within the overall Government Vision 2025.

Access to health services Tanzania Service Provision Assessment Survey of 2006 indicated that “basic services” were available in over 75 percent of facilities. Basic services include curative care for sick children, child immunization and growth monitoring, STI, family planning and ante natal care services. Curative care for sick children and STI services are, on average, available in all facilities, whereas other services are available in approximately 8 in 10 facilities. In terms of access to health services, there are a number of factors that affect the patients’/clients’ either positively or negatively. The introduction of cost-sharing exercise in the health service provision had adverse effect to vulnerable groups due to their economic status. Having noted that, the government in the National Ageing Policy, National Disability Policy and National Strategy for Growth and Reduction of Poverty directed the establishment of interventions that will facilitate and ensure accessibility of health services to vulnerable groups freely and

without discrimination. Distances to health facilities and long queues Clients at health facilities often experience long distances and queues. The problem is largely attributed to the shortage of staff. On the other hand

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some facilities serve a very large population, facilities being far from settlements, limited equipment, shortage of drugs and other supplies. In some areas there are physical barriers to an existing facility though it may be within 5 kilometres of a population centre. Geographical barriers include rivers, lakes, bad roads, valleys and mountains. There are many examples of non-functioning facilities scattered in the districts. This is also a barrier to access. Irregular availability of drugs The “out of stock” phenomenon of essential drugs and supplies is a main factor that discourages access” of services at health facilities. Considerably, challenges in provision of access to health services including long distances to health facilities, inadequate and unaffordable transport systems and continuous limited quality of care In the light of the above critical parameters that amply justify this intervention programme, the ultimate goal is inevitably the strengthening of district health services so as to make them more effective and sustainable. Given our natural barriers, communication systems, roads and the poverty line, there is a need of putting a health care facility in each village disregarding the concept of 5,000 people to qualify for a dispensary. The services should ultimately be accessible to the whole Tanzanian population with a focus on rural areas and particularly those most at risk. Essential drugs and medical supplies Availability of medicines, medical supplies and equipment is necessary for the provision of health services. The items have a special importance because they save lives, improve health of patients, promote trust of patients to the health delivery system and enhance participation and ownership of the services. Most of deaths and causes of sufferings and disabilities can be prevented, treated or alleviated with essential medicines, medical supplies and equipment.

Provision of health services in Tanzania faces a number of challenges, most notably the inadequacy of equity in access to essential medicines and related supplies, with a consequent impact on quality of care. Availability of medicines, medical supplies and equipment in health facilities is one of the factors that make patients to visit them for services. Some health

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facilities are preferred to others because of availability of medicines, medical supplies and equipment. Therefore, it is important to maintain uninterrupted supply of these items in the health facilities at all times.

Expenditure on medicines, medical supplies and equipment in Tanzania is second only to personal emolument. The expenditure represents more than a third of the health budget. Since the budget is generally limited, the country has experienced a disproportion between the needs and allocated budget for the purchase of medicines and medical supplies. Since 1984, dispensaries and health centres have been supplied with medicines and related supplies through a push system (drug kits). Although the system is easy to operate, it is unable to address needs of health facilities due to the difference in morbidity pattern resulting into wastages and shortages of medicines and related supplies in health facilities. In order to ensure a reliable supply of medicines, equipment and medical supplies in these facilities, the MOHSW has developed systems that would ensure provision of the items according to needs taking into consideration of budget allocation. It is envisaged that the system will be operational in all public health facilities by 2010. The provision of health services is costly. In this regard, the Government has been adapting different ways and mechanisms of financing the health sector. These mechanisms include, among others, cost sharing schemes such as Capitalization of Hospital Pharmacies, Community Health Fund (CHF) and National Health Insurance Fund (NHIF). The Ministry of Health and Social Welfare decided to introduce cost sharing schemes as alternative financing mechanism to raise funds for complimenting government budget for provision of health services in addition, to sensitize community sense of ownership. Household surveys conducted in different parts of the world have shown that cost of medicines and related supplies represents the major out-of-pocket of health expenditures incurred by households. Price survey of medicines conducted in Tanzania in 2004 in the public, private, and non-governmental organizations (NGO) health facilities revealed that there were significant inter-sectoral price variations whereby the prices in the NGO and private facilities were higher than those in the public sector. Valuable information was also documented on the various mark-ups and add-ons by NGO and private health facilities to the wholesalers/manufacturer’s price. It was noted in this report that majority of Tanzanians are not be able to afford

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to pay for essential medicines and related supplies and therefore depend on services provided by public health facilities.

Transportation

It is the Government’s policy to provide district and regional transport and vehicle replacement. In the early useful life of the vehicle 5 years, the maintenance costs are very low due to light repairs. The cost escalations start from the fourth year and hence become uneconomical to operate and also a burden to the users and in most cases the users put a plan for replacement when it is at this state. Assessing the current situation of the Primary Health Care transport fleet composition and status in the councils is that: • A total of 132 vehicles representing 57.4% of the vehicle fleet are over

the age of 5 years. These are prone to draining funds in terms of huge vehicle repair costs. Ideally according to the vehicle replacement policy, they are overdue for replacement but due to insufficient funds they have continued to be used in the system.

• The remaining 98 vehicles representing 42.6% are within the age of 5 years as recommended in the Ministry of Health and Social Welfare transport policy and therefore are in good running condition.

• Vehicles under vehicle off road (VoR) condition are 6 representing 2.6%.

• While 49 vehicles representing 21.3% of the vehicle fleet are under repairable condition but are being repaired at an exorbitant cost.

• Vehicles serviceable, which are in varying degrees of running condition, are 175 representing 76.1% of the total fleet.

• The 132 vehicles which are over the age of 5 years need to be replaced immediately if saving on uncalled for repair costs is to be realised as well as improvement of the operational status of vehicles in the councils.

• Basically, there is one funding mechanism option used for the replacement of vehicles in the councils but also with their shortcomings

Vehicle Replacement Using Block Grants and Government Subventions

At present vehicle depreciation is not taken into account when calculating a vehicle’s operating cost. As such no provision is being made at council level to replace a vehicle once it has passed its economic life other than making provision within the capital vote of the annual budget.

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Through the MTEF, funds for vehicle replacement have usually been set aside centrally for the procurement of vehicles. The trend of allocation of vehicle replacement over the years has been as follows

S/NO FINANCIAL YEAR EXPENDITURE 1 2001/2002 276,000,000 2 2002/2003 1,100,000,000 3 2003/2004 1,300,000,000 4 2004/2005 1,250,000,000

As can be seen above, if funding provided annually remains at last year’s figure of Tshs. 1,250,000,000, it will take 6 years to replace the current fleet of 132 vehicles that need to be replaced now! By the end of 6 years, the current 42.6% of vehicles that are less than 5 years will be waiting in the queue to be replaced as well.

Vehicle replacement is therefore rather an add-hoc process, being dependent on the approval of others and the receipt of sufficient funds in any given financial year. Original plan was to procure 45 vehicles annually for the fleet to be fit for the purpose health delivery services. In order to have sufficient funds for vehicle replacement the Councils will require setting up depreciation/retention accounts and for councils to be disciplined in ensuring that the equivalent annual depreciation cost of running a vehicle is deposited into these accounts

The large sums involved in setting up of such accounts will also focus a council’s awareness on the need to only operate sufficient vehicles to meet the operational demands of the individual departments. Adapting good transport management systems will enable councils to identify those vehicles that are superfluous to requirements which can be disposed of and the financial savings, both capital and operational, redirected into other development programmes.

Communication System In order to strengthen the referral system from the dispensary to the health centre, there is a need of placing an ambulance and a mortar cycle in each health centre and, radio call system in each district. Currently some districts have received funds to support their communication system, which is one of the inputs to strengthen the referral system.

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There is inadequate transportation at health facilities and in communities in general specifically there are insufficient vehicles to provide administrative, supervisory or logistical support for the Districts. The situation is even worse when the transportation of the sick and injured is considered. Vehicles designated as ambulances are typically used for administrative and logistical functions.

Key activities need to be implemented which include procurement and installation of appropriate communication equipment (radio call system) and emergency transportation means to facilities and community interventions such as outreach service, educational campaigns , establishing community emergency preparedness mechanism.

Health infrastructure network and medical equipment The infrastructure part of the primary health care services network encompasses dispensaries, health centres and district hospitals. The Health Services Delivery System in Tanzania consists of a network of facilities, which assumes a pyramidal Structure starting from a Dispensary, Health Centre through the District and the Regional Hospitals to the Referral Hospitals. In principle the referral system is designed for the dispensary to refer patients to health centres and for the health centres in turn to refer patients into hospitals. Unfortunately this system is not functioning as intended. A number of factors contribute to this situation, among others, under funding, weak management arrangements, inadequate staff and difficulties in transport and communication. The 2006 Health Policy recognize the importance of accessible and sustainable Primary Health Care services for all citizens through provision of dispensary in every village, a health centre in every ward and, a hospital in every district. However, with the given country size, population and, the geographical barriers, the health services are not easily accessible to all. The private sector is contributing approximately 40 percent in the provision of health service delivery. The distribution of health facilities on Mainland Tanzania by ownership shows that the government owns 64.2 percent of all facilities, voluntary agencies 17.7 percent, parastatal, and private institutions has 3.0 percent and 15.0 percent, of the facilities respectively.

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The distribution by ownership shows how different stakeholders supplement government efforts in providing quality health services in the country. The proportion of government health facilities in good state of repair can also be used as proxy indicator for good quality services.

Most of the Tanzania population 90% now lives within 5 kms. Only 10% are 10 kms from a health facility (MOHSW 2006; HSA). However, due to geographical barriers and difficulties for the sick and pregnant women to cover such a distance when services are needed, more facilities are still required.

Table 1: Distribution of Hospitals and Health Centres by Regions and ownership in year 2004/2005

Source: Health Statistical Abstract, April 2006

Gvt.= Government, Vol= Voluntary Agencies, Par = Parastatal, Pvt = Private Health Facilities

Hospitals Health Centres Region Gvt Vol par Pvt Total Gvt. Vol Par Pvt Total

Dodoma 5 2 0 0 7 18 2 0 1 21 Manyara 4 2 0 0 6 4 7 0 0 11 Arusha 3 7 1 1 12 16 5 2 6 29 Kilimanjaro 5 9 1 3 18 21 4 1 6 32 Tanga 5 4 0 3 12 18 7 0 0 25 Morogoro 5 4 1 2 12 21 5 3 2 31 Coast 5 1 1 0 7 15 1 0 1 17 Dar es Salaam 4 2 2 19 27 5 7 2 9 23 Lindi 5 3 1 0 9 13 1 0 1 15 Mtwara 4 1 0 0 5 12 2 0 0 14 Ruvuma 3 5 0 0 8 8 3 0 0 11 Iringa 5 6 0 4 15 19 14 1 0 34 Singida 3 6 0 0 9 11 2 0 1 14 Mbeya 6 8 0 2 16 20 7 0 1 28 Tabora 4 3 0 0 7 12 2 0 1 15 Rukwa 2 1 0 0 3 20 8 0 0 28 Kigoma 3 2 0 0 5 13 4 1 0 18 Shinyanga 5 1 1 1 8 23 2 0 1 26 Kagera 2 10 0 1 13 17 11 0 2 30 Mwanza 6 6 0 1 13 32 3 0 4 39 Mara 3 4 0 0 7 13 4 0 3 20 Total 87 87 8 37 219 331 101 10 39 481

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Table 2; Distribution of dispensaries and total health facilities by region and ownership year 2004/05

Dispensaries All Health Facilities Region Gvt Vol Par Pvt Total Gvt. Vol Par Pvt Total

Dodoma 185 28 12 15 240 208 32 12 16 268 Manyara 75 36 1 11 123 83 45 1 11 140 Arusha 89 60 7 40 196 108 72 10 47 237 Kilimanjaro 149 63 7 113 332 175 76 9 122 382 Tanga 186 23 0 22 231 209 34 0 25 268 Morogoro 159 49 13 28 249 185 58 17 32 292 Coast 128 28 10 16 182 148 30 11 17 206 Dar es Salaam 71 28 11 230 340 80 38 15 258 390 Lindi 135 6 7 6 154 153 10 8 7 178 Mtwara 128 12 1 11 152 144 15 1 11 170 Ruvuma 127 31 3 13 174 138 39 3 13 193 Iringa 190 70 5 17 282 214 90 6 21 331 Singida 89 38 0 8 135 103 46 0 9 158 Mbeya 227 40 7 33 307 253 55 7 36 351 Tabora 156 22 2 27 207 172 27 2 28 229 Rukwa 156 11 0 17 184 178 20 0 17 215 Kigoma 164 17 7 8 196 180 23 8 8 219 Shinyanga 108 52 23 33 216 136 55 24 35 250 Kagera 142 99 4 10 255 161 120 4 13 298 Mwanza 243 25 16 52 336 281 34 16 57 388 Mara 131 25 9 23 188 147 33 9 26 215 Total 3,038 763 145 733 4,679 3,456 952 163 809 5379

Source: Health Statistical Abstract, April 2006 Gvt.= Government, Vol= Voluntary Agencies, Par = Parastatal, Pvt = Private Health Facilities

The physical condition of the health facility buildings (infrastructure) is poor. More than 50% of them require urgent major rehabilitation or complete reconstruction. There is also lack of adequate space for service provision as more than 60% of the health facilities do not have the required number of rooms in accordance with the standards defined by the Ministry of Health and Social Welfare. Most of the health care facilities have a working or service delivery space that is less than 50% of the requirement, the maternal and child health being the most constrained than other services areas.

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The aim of the Government is to improve the access, quality and efficiency of district based health services by strengthening the planning and management capacity of decentralized district health and administrative system, through construction, rehabilitation, extension and provision of equipment and furniture for the health facilities rendering the primary health service. This programme aims to help in achieving this goal and guide future health facility development. A well-designed and constructed health facility shall consist of the following basic components:

• Buildings, • Roads and drainage • Walkways, parking and landscaping • Security fences and lighting • Water supply • Sewerage system • Solid waste management/incinerator • Power supply

Water Supply Reliable water supply is essential for improved hygiene and provision of health services. The principle sources of water supply are surface and ground or sub-soil water. Most of the dispensaries and health centre do not have reliable water supply and in most cases where water exist the system has deteriorated beyond repair. Most of the district hospitals are connected to piped supply of the urban water and sewerage systems. However it is prudent to supplement the piped water supply with sub-surface water from shallow wells and/or boreholes. Rainwater harvesting with water reservoirs is highly recommended in places where the other sources are not available.

In the context of this programme it is assumed that all dispensaries and health centres situated in rural settings do not have reliable water supply. It is suggested that all these facilities be provided with this essential amenity. The introduction of safe water supply in these facilities will eventually benefit both facility and the communities. Dispensaries A standard dispensary consists of out-patient-department, maternal and child health services, toilets and a minimum of two staff quarters. The current situation with dispensaries is as follows:

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Total number of villages 10,342 Total number of existing dispensaries; 4,679 Total number of health centres; 481 Total number of villages without dispensaries; 5,162 Note: A village with a health centre does not need a dispensary which entails that the total number of dispensaries required is (5162-2074) 3,088

It has been established that more than 50%1 of the dispensaries are in bad state of repair. PMO RALG, with assistance from the Development Partners is currently rehabilitating 25% PHC facilities in Tanzania with the remaining 25% of the existing health facilities in poor state, which need to be rehabilitated under this programme, is 1170 dispensaries.

Most of the existing dispensaries are operating without a space for maternal and child health services. Approximately 70%2 of the dispensaries lack this necessary element of the facility.

Staff houses form an integral part of the dispensary, however in most cases these have been neglected during the construction of these units and where they exist are in a very bad state of repair. It is assumed that 80%3 of the dispensaries lack modest staff houses the provision of which will give impetus to the health service delivery. Health Centres A standard health centre consists of out-patient-department, maternal and child health services, 24 beds medical ward for female and male, obstetrics theatre, diagnostic services, mortuary, surf-burner (improvised incinerator), kitchen, store, and a minimum of 10 staff quarters 2 out of them being grade ‘A staff quarters’. The current situation with Health Centres is as follows:

• Total number of wards; 2555 • Total number of existing health centres; 481 • Total number of health facilities required; 2074

The MoHSW, PMORALG with support of Development Partners have put in place a District Health Infrastructure Rehabilitation Component (DHIRC) and a special Rehabilitation Fund (JRF) was established to finance this rehabilitation.

1 The percentage has been arrived at in the Rehabilitation Needs Assessment Study by PMO-RALG 2 From the Three Regions Health Study 3 From the Situation Analysis Report for preparation of Standard Guidelines and Drawings by PMO-RALG

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25% of the primary health infrastructure will be rehabilitated under this arrangement. 25% more will be rehabilitated by using Local Government Capital Development Grant and Tanzania Social Action Funds. The rest 50% of the PHC- infrastructure is still in poor state of repair. About 120 Health centres will be addressed under this programme.

Most of the existing health centres are operating without adequate space for maternal and child health services. It is held that 40% of the health centres lack this necessary element of the facility. Furthermore obstetric theatres will be constructed in each health centre to improve health service delivery.

Staff houses form an integral part of the Health Centre, however in some cases these have not been given the required credence during the construction of these units and where they exist are in a very bad state of repair. It is assumed that 30% of the health centres lack adequate and suitable staff houses and 60% of the existing staff houses are in bad state of repair. The provision of staff houses is a fundamental necessity and will give the required impetus to the health service delivery. District Hospitals Also known as Level-1 Hospital care, it is provided in: • District and Designated District Hospitals (DDH) serving 133 Local

Authorities in the country; • A number of other hospitals in districts owned and run by voluntary agencies

or private institutions.

District hospitals are an integral part of the PHC system forming the apex of a system of dispensaries and health centres. District and other level I hospitals are either owned by the government or voluntary institutions. A few private hospitals now exist but mostly in urban areas. Government district hospitals are the responsibility of Local Authorities, funded through the Prime Minister’s Office Regional Administration and Local Government.

In districts where there is no government hospital, a voluntary agency hospital is contracted by the Ministry of Health & Social Welfare to serve as a Designated District Hospital (DDH). It is worth noting that certain voluntary agency hospitals are providing or have the capacity to provide some level II hospital care (for example St. Francis Hospital in Kilombero District, Morogoro Region or Ndanda Hospital in Masasi District, Mtwara Region).

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The current situation with District Hospitals is as follows: • Total number of districts; 114 • Total number of district and designated district hospitals 95 • Total number of district hospitals required; 19

The existing district hospital infrastructure is not adequate and mostly not suitable to support provision of quality basic curative and preventive services to the population it serve.

Lack of privacy in the inpatient wards, consultation and counselling rooms together with overcrowding in diagnostic and inpatient wards, long waiting queues in diagnostic areas and lack of functioning equipment; all have shown to deter the delivery of quality health services.

The state of hospitals’ infrastructure is generally in poor condition and the electrical and mechanical installations such as incinerator equipment and mortuary body cabinets need urgent repair and replacements. A recent study by Mekon Arch Consult under PMO-RALG revealed that more than two thirds of all buildings require urgent repair, renovation or reconstruction.

Referral System

In the context of the Tanzania health system, the planned referral system is basically non-functional due to a number of reasons: • Critical shortage of the core health human resources from the

dispensaries upward to health centres to district hospitals to deliver core services at those levels to reduce unnecessary referrals due to lack of the required skills;

• Inadequate or inability to complete diagnostic check up at dispensaries and district hospitals;

• Lack of transportation and communication facilities to operationalize organized referrals and feedback processes from the lower levels to the district hospitals and higher up the referral chain;

• Irregular supply of essential drugs necessary at levels of the health delivery system to minimize unnecessary referrals.

• Lack of communication, between various health service providers within districts and regions to maximize utilization of existing skills and facilities, particularly in private facilities, towards promoting horizontal referral of patients

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This situation leads to self-referrals and by pass of the referral system by patients, unnecessary referrals by unskilled staff at the various levels of the health care delivery system. This undermines the users’ trust and credibility of the sector. For the purposes of the PHSDP, innovative and at times unconventional mechanisms will be required to ensure timely and a smooth referral system while maximizing on locally available facilities and skills within districts and regions in order to ensure continuity of care. This will ensure organized and timely access to specialized referral services for populations within all districts across Tanzania.

4.3 Maternal, Newborn and Child Health Maternal, newborn and child health care are key components of National Package of Essential Reproductive and Child Health Interventions focusing on improving quality of life of women, adolescents and children. The major elements of the package include antenatal care, care during childbirth, Emergency Obstetric Care (EmOC), Newborn care, postpartum care, and Childcare. It is estimated that over 80% of the Tanzanian population live within 5km from the health facility, in spite of the good coverage of health facilities, not all components of the services are provided to scale, hence, maternal, newborn and child mortalities remain a major public health challenge in Tanzania. Maternal mortality ratio is 578 deaths per 100,000 lives births (TDHS 2004). Over 80% of the maternal deaths are due to direct causes that includes obstetric, haemorrhages, obstructed labour, pregnancy induced hypertension, sepsis and abortion complications. The majority of maternal deaths can be prevented if pregnant women can be assured of access to skilled attendance4 at childbirth and emergency obstetric care when pregnancy related complications arise. According to TDHS 2004, 94% of pregnant women attend antenatal care at least once and 68% for 4 visits. However, the quality of antenatal care provided is inadequate. About 65% of the women have their blood pressure measured and 54% have blood sample taken for haemoglobin estimation and syphilis screening. About 41% have urine analysis done and only 47% are informed of the danger signs in pregnancy and childbirth. Regardless of high ANC attendance, only 47% of births occur

4 - Making Pregnancy Safer: The Critical Role of the Skilled Attendant, A Joint Statement by WHO, ICM & FIGO, 2004

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at health facilities. Of all deliveries occurring in health facilities, only 46% are attended by skilled attendants. Major barriers perceived by women to access delivery health services include lack of money (40%), long distance to a health facility (38%), lack of transport (37%), and unfriendly services (14%). The high rates of home deliveries are also attributed by poor geographical access to health facility, lack of functioning referral system, inadequate capacity at health facilities in terms of space, skilled attendants, commodities and other socio-cultural aspects surrounding the pregnant women. Additional factors include gender inequalities in decision-making and access to resources at household level. Emergency obstetric care services are crucial in addressing complicated pregnancies. However, lack of functioning blood banks at most hospital and health centres in Tanzania is correlated with the low rate of caesarean section5, whereby only 3% of babies born are delivered by caesarean section (TDHS2004). 64.5% of hospitals provide comprehensive emergency obstetric care (EmOC), whereas only 5.5% of health centres are providing Basic Emergency Obstetric Care6. Furthermore, the referral system has serious challenges including limited number of ambulances; unreliable logistics and communication system; and low community based facilitated referral system. Adolescent friendly Reproductive Health services need to be addressed as young people under the age of 24 make up nearly two-thirds of the Tanzanian population. Young people have special concerns that must be addressed in regards to Maternal and Neonatal health. According to some recent studies have shown that: Infant mortality is highest in countries with the largest proportion of births to adolescents7; Children born to adolescents are much more likely to die than those born to women ages 20 to 298 and Maternal mortality is as twice as high for young women, ages 15-19, than it is for women, ages 20-349In order to effectively reduce maternal and child morbidity and mortality the needs of young people must be addressed. In Tanzania10, more than half of young women under

5 International recommendation is caesarean section between 5-15% 6 2005 Unpublished Public Facility EmOC Survey 7 : Zwicker C et al. Commitments: Youth Reproductive Health, the World Bank and the Millennium Development Goals. Washington D.C.: Global Health Council 2004 8 Zwicker 9 Mathur S et al. Too Young to Wed. Washington D.C.: International Center for Research on Women, 2003 10. 2005 Tanzania Demographic and Health Survey 2004-05. Dar es Salaam, Tanzania: National Bureau of Statistics, Tanzania, and ORC Marco

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the age of 19 are pregnant or already mothers; the perinatal mortality rate (per 1,000 pregnancies) is significantly higher for young women under the age of 20 (56), that it is for women aged 20-20 (39), and older women aged 30-39 (32). Child mortality remains a serious public health concern in Tanzania. Neonatal Infant and under five mortality Rates stand at 32, 68 and 112 per 1000 live births respectively (TDHS 2004). Malnutrition indicators are also poor with underweight, stunting and wasting at 22, 38 and 3% respectively. The recent gains in child survival have been attributed to among others Vitamin A supplementation, IMCI and high immunization coverage (80% for all antigens). Although there have been gains of recent, Tanzania is still loosing unacceptable number of children every year. Neonatal death continues to contributes significantly to the under five mortality and like maternal mortality has not shown any decline for over a decade. More than 70 percent of under five deaths are attributed to easily preventable and treatable conditions/diseases including malaria, pneumonia, diarrhoea, malnutrition and perinatal conditions. Deaths in the first month of life account for about one third of all deaths in under five children. The main causes of neonatal deaths are complications related to delivery or preterm births and infections. Most deaths during neonatal period are due to causes related to risk factors due to pregnancy and delivery. Safe delivery and immediate postnatal care are critical since approximately 40% of neonatal deaths occur during the first day of life. Most deaths during late neonatal period are due to infections. Tanzania is considered as one of the few countries which are on track in achieving MDG 4.

Weakness in the health system has direct impact on the delivery of maternal and newborn services i.e. shortage of skilled providers in most of health units, lack or inadequate supplies equipments, poor infrastructures, inadequate and poor referral system. To be able to reach the MDG 4 & MDG5 targets by 2015 substantive efforts has to be made in strengthening the existing system and expand and decentralize further services, this implies a comprehensive approach is required to improve coverage within all districts with emphasis of reaching every child and woman and youth with essential effective interventions.

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Hence proposed actions are aimed at ensuring provision of adequate services and care during childhood, adolescence, pregnancy, post-natal, delivery and prompt emergency care to prevent morbidity and death from obstetric complications including prevention of unwanted pregnancies.

4.4 The National AIDS Control Programme The National AIDS Control Programme (NACP) of the Ministry of Health and Social Welfare (MOHSW) plans to expand and strengthen the care, treatment and support services to rural communities and make the services accessible to all in need by 2017. Based on the targets that were set in the previous Health Sector Strategy for HIV/AIDS (2003 – 2006), the NACP is currently providing care and treatment services in 200 facilities across the country. The facilities include; referral, regional, district hospitals and also non-Governmental organization and faith based owned hospitals. From year 2007, the services will expand to rural communities by including 500 primary health care facilities of health centres and dispensaries. The number of patients to be initiated with anti-retroviral drugs (ARVs) is expected to increase from the targeted 440,000 in the year 2008 to 800,000 in 2017.

The increased number of patients accessing care, treatment and support services including ARVs will increase substantially the demand for HIV test kits, laboratory equipment and supplies for screening and monitoring of patients on Care and Treatment. Currently, the Haematology Analyzers are available in only 141 health facilities. Chemistry analyzers are available in 148 health facilities. The FACS count machines for determining the levels of CD4 have been distributed in 4 Referral hospitals, 18 Regional hospitals, 19 District hospitals, 1 NGO hospital and 1 military hospital. To expand these services to the community, the NACP plans to distribute CD4 count machines to all remaining district hospitals and other hospitals owned by Faith based organizations. Patients’ blood samples for CD4, chemistry and haematology analyses from remote health and HIV testing sites will be transported to the nearest care and treatment facilities that are equipped with respective equipment. HIV infant diagnosis has also been established in referral hospitals. Patients’ blood samples will be transported from the health facilities around the zonal catchment’s areas. With such extensive laboratory support, it is expected that more than 800,000 patients will access these services countrywide by 2017.

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Counselling and testing is the entry point for care, treatment and support for people living with HIV/AIDS (PLHA). Services have been established in 1,027 sites (3 Voluntary Counselling and Testing (VCT) sites in each district). Though VCT has been the main recruiting ground for patients accessing care, treatment and support services, this avenue is insufficient and inadequate to meet the target set for Care and Treatment enrolment. It is planned therefore, to introduce Provider Initiated so that all patients coming in-touch with the health system will be offered Counselling and Testing. It is expected that the majority of 20 million of the population attending out-patients and in-patients department will accept to undertake the test and identify the eligible persons for care, treatment and support services. By 2017, the NACP plans to scale up quality counselling and testing services in the country from 15% to 60% of the population aged 15 – 49 years.

Community Home Based Care (CHBC) acts as a health facility and community linkage system for providing basic nursing and medical care at home including counselling, care and support. It is therefore an important link for monitoring of patients. CHBC services have been established in more than 70 districts. A total of 1,400 HBC providers have been trained at the health centres and dispensaries and more than 200 HBC providers have been trained at the community level. The plan by 2017 is to implement CHBC service in all districts and have at least two CHBC service providers in every village.

Sexually Transmitted Infections (STI) control programme focuses on strengthening STI treatment practices in health facilities using STI syndromic case management approach. STI services have now been established in all 21 regions of Tanzania Mainland, covering all public hospitals, health centres, 60% of dispensaries and some private owned facilities. The plan by 2017 is to further expand STI services to all remaining public and private facilities, to ensure the continuous availability of essential STI drugs to all health facilities offering STI services and ensure syphilis screening is offered to all pregnant mothers on their first ANC visit.

Prevention of Mother to Child services has been expanded to all regional hospitals and other 145 hospitals including district and faith based owned hospitals, 182 health centres and 332 dispensaries. Already 255,913 pregnant women have been reached with PMTCT services. Guidelines

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have been developed and 2,758 providers have been trained. The plan is to reach 85% of the pregnant women by strengthening PMTCT programme management and coordination by 2017. The NACP plans to increase facility coverage through integration of PMTCT services into routine RCH services in hospitals, health centres and dispensaries and to provide anti-retroviral (ARVs) prophylaxis to 75% of all HIV+ pregnant women who are not eligible for anti-retroviral therapy (ART).

In promoting health and behavioural change, the NACP has been using various approaches to reach specific groups of people as well as the general population. These approaches include production of Information, Education and Communication (IEC) print materials such as posters, leaflets, wall calendars, newsletters, brochures as well as electronic media (TV and Radio Programmes). The plan is to further promote positive behavioural change towards HIV/AIDS/STI through health promotion by producing more print materials and distribute them to the community especially in the villages. Also to produce more educative radio and television programmes and air on various channels especially those which reach the rural areas. In addition, the NACP library continues to maintain a variety of informative resource materials in form of reports, guidelines, training manuals, books on HIV/AIDS/STI, CD-ROMS which can be utilized by researchers, academicians, students and the general public free of charge. Since 2006, the Programme made an attempt to move towards digital distribution of its HIV/AIDS information through the global network infrastructure by establishing a website (www.nacptz.org). The plan is to increase access to HIV/AIDS/STI information to clients.

4.5 Malaria Malaria currently kills up to 3 million people per year worldwide, most of them being children below five years of age and pregnant women. About 90 % of all malaria deaths in the world today occur in Africa south of the Sahara. This is because the majority of infections in Africa are caused by Plasmodium falciparum, the most dangerous of the four human malaria parasites. It is also because the most effective malaria vector – the mosquito Anopheles gambiae sensu lato – is the most widespread in Africa and the most difficult to control (WHO, 2003). The impact of malaria on the poor is exacerbated by hunger, malnutrition, anaemia coupled with other diseases associated with poverty.

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The number of clinical malaria cases per year is estimated to be 17 – 20 million resulting in approximately 100,000 deaths. The population groups most vulnerable to malaria are children under five years and pregnant women, due to their particular immunity status. The current estimated infant mortality and under five year mortality rates are 68 and 112 per 1,000 live births respectively (2004-05 TDHS). Maternal mortality is estimated at 578 deaths per 100,000 live births. Life expectancy at birth is 45 years. It has been estimated that malaria contributes to about 36% of all deaths in children under five years of age (IHRDC-DSS, 2005).

As part of the review of the Malaria strategic plan 2002-7 conducted in late 2006 and early 2007 as a process of developing a New NMMSP 2008-12, it was revealed the following are the weakness and threats within the malaria control strategies. Major weakness have been identified to include; Low percentage of malaria confirmed cases and malaria over diagnosis; on the other hand more than 95% of all febrile patients receive an anti-malarial treatment, which means that the wastage of drugs is equivalent to the magnitude as the over-diagnosis. Unclear stipulated malaria quality system from the diagnostic unit in the MOHSW were observed; Absence of strategic actions to address Integrated Malaria Vector Control issues has resulted to the increase of burden of disease in the country; Weak infrastructures and Inadequate knowledge and skills within the community to manage environmental management reduced participation at grass root level; Lack of enforceable legislations (Mosquitoes Extermination Ordinance of 1935 is out-dated) has resulted into scattered breeding sited.

The vision of the new strategy is that, Tanzania becomes a society where malaria is no longer a threat to the health of its citizens regardless of gender, religious or socio-economic status. The mission is to ensure that, Tanzanians have universal access to malaria interventions through effective and sustainable collaborative efforts with partners at all levels.

4.6 Tuberculosis and Leprosy 4.6.1 Tuberculosis

Tuberculosis continues to be among the major public health problems in the country accounting for 7% of the burden of disease in the country up from 5% in 1999. The number of tuberculosis cases notified in country has steadily increased from 11,753 in 1983 to over 64,000 in 2004, which is

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almost six-fold increase. Data from AMMP shows that TB is the third cause of deaths among adults after malaria and HIV/AIDS.

Majority of TB cases are young adults aged 15-45 years, the same age group affected by HIV/AIDS. Nearly two thirds of all TB cases notified are males. Various studies conducted in the country show that the rapid increase of tuberculosis is mainly attributed to the HIV epidemic, but other contributing factors include population growth and overcrowding especially in urban settings. TB is one of the earlier indicators of HIV infection and it is estimated that 40-50% of all HIV infected individuals in Tanzania may develop tuberculosis during their life time. Similarly TB is the leading cause of death among AIDS patients accounting for about 30% of all AIDS-related deaths. Other consequences include stigmatisation of the TB diagnosis, which is automatically associated with HIV/AIDS by health workers and the community at large. The distribution of TB in the country is not equal. Almost two thirds of all cases are reported by 7 regions alone - Dar es Salaam, Arusha, Tanga, Morogoro, Iringa, Mbeya and Mwanza). Dar es Salaam alone notifies about 25% of all forms of TB cases notified in the country annually.

Another dangerous aspect of tuberculosis is the spread of multi-drug resistant TB (MDR-TB), which threatens to reverse achievements so far gained in TB control in the country. Available NTLP routine surveillance data indicates that the problem is still low around 1%. Despite the low prevalence, there are a substantial number of MDR-TB cases that are documented in different hospitals and among health care workers. Referral centres like Kibong’oto attend to a number of patients who have failed TB treatment regimens in other settings. The absence of a policy on follow-up of these cases or treatment regimen could easily increase transmission to the general population

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4.6.2 Leprosy The number of registered leprosy cases notified annually has decreased from over 35,000 cases in 1983 to about 4,500 in the year 2004. About 8% of the annual notified cases are children under 15 years of age and 10% have permanent disability according to WHO classification. The number of newly notified cases has not significantly changed in the last one decade despite intensification of leprosy elimination campaigns. The number of registered leprosy in Tanzania in the year 2004 was 1.4 per 10,000 populations which is still above the World Health Organisation (WHO) target of 1 case per 10,000 populations. The disease still continues to have a very negative social image in the community, frequently responsible for discrimination and stigmatisation. Patients also face serious psychological problems including loss of marriage prospects. The stigma and cultural association of leprosy with evil spirits causes many victims to seek assistance from traditional healers before reporting to health services. Additionally many general health workers are not able differentiate leprosy from other skin diseases when it is presented to them at an early stage without nerve damage and deformities.

4.7 Health Promotion and Education The coverage of Primary Health Care services is still unacceptably low. The target was to provide PHC services for all by the year 2000. Health and health related problems are unlimited as reflected by high Burden of Diseases (BOD) for both communicable and non-communicable diseases while resources are limited. Health seeking behaviour is poor, thus leading to high morbidity and mortality of diseases. The health sector is striving to improve accessibility and quality care for the public. One of the strategies is to implement PHSDP. Social mobilisation and public awareness is a critical step in the success of the programme. Health Education and Health Promotion will enhance delivery of Primary health services to the community focusing on RCH, HIV/AIDS, TB and Malaria.

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In order to facilitate smooth and sustainable implementation of the program (PHSDP), health education and promotion will: Strengthen prevention of communicable and non-communicable diseases Increase community awareness and health seeking behaviour Increase community involvement, social mobilisation and participation in health services

4.8 Nutrition The incidence of under nutrition is high although there has been considerable improvement recently. The percent of stunted children has dropped from 44% to 38% between 1999 and 2004. Better progress has also been recorded for underweight which has fallen from 29% to 22% during the same period. Despite this progress, district and community levels response and action for nutrition has remained weak. The weakness is a result of non- availability of accountable staff for nutrition at these levels. There are no designated nutrition focal personnel to coordinate nutrition actions at these levels. There is therefore, a need to build capacity for nutrition at district levels by recruiting or deploying health staff at these levels. The staff will provide technical support and ensure coordination among health programmes in relation to nutrition as well as to ensure linkage with other sectors.

4.9 Public Private Partnership The growing demand for health care services posed by evolution of emerging and re-emerging diseases has put more pressure on the health care delivery system in terms of increased need for extra resources and expertise. The continuing resource shortage for health necessitated the government to reintroduce private health practice for profit in 1991, which had in the past been restricted since 1977. This is aimed at assuring that the private sector services complement health care services provided by the government in efforts to narrow down the existing gap that cannot be filled by the government on its own.

Private sector health facilities account for some 40 percent of the total facilities in the country. Of this total, 35 percent are Faith Based Organizations owned of which most are located in disadvantaged areas of the country. Some of them are funded by government through grants; basket funds and other forms of support e.g. medicines, equipment, staff secondment and training.

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On the other hand, almost 90 percent of private for profit health facilities are situated in urban areas, a ratio that is inconsistent with the population distribution in the country whereby about 80 percent live in rural areas while only 20 percent in urban areas. This Programme will take into account the already existing initiatives geared towards promoting and sustaining Public Private Partnerships in health service provision. Strengthening the health infrastructure network through constructing new ones, repair and rehabilitation works and provision of non core services is to be done by the private sector. Through PHSDP, the government will put increased effort on district health services and further consolidate involvement of the various stakeholders at that level while continuing to maintain its fundamental role of ensuring provision of quality health services to all citizens.

4.10 Traditional and Alternative Medicine. In Tanzania, traditional health practices have been practiced before, during and after colonialism. It is estimated that about 60% of all health seeking population depends on traditional health services and that about 53% of all home deliveries majority of them are attended by traditional birth attendants. Similarly, it is estimated that there are about 40,000 traditional healers and 32,000 traditional birth attendants Countrywide. Traditional health practitioners including healers and birth attendants are very much respected especially by the rural population, hence, there is a tendency to first consult traditional healers and only visit modern health services as a last resort. Some of the patients who are already in the hands of modern health services, however, continue to receive traditional health services. In general the quality of health services in traditional health system is still unsatisfactory. The causes of this state of affairs are many, ranging from un institutionalisation of the service, less formal education of the practitioners and the use of material medical which does not conform to formal pharmaceutical level (is not standardized). Similarly, traditional health services have been affected by lack of documentation in the services provided, encroachment of un ethical people in the services, lack of research which aimed at improving the practices and lack of formal training in traditional health services to young generation and especially medical and paramedical students in the training institutions (in both traditional and modern training settings).

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Unfortunately, majority of traditional health services providers lack the necessary skills for rational patient care. Their practices are usually not in accordance with the formal trainings of health services provisions leading to unsafe and patients end up in complications and at times avoidable death. The evolution of new diseases like AIDS and development of resistance to treatment by common medicines for diseases like Malaria and other emerging and re-emerging diseases and change of lifestyle have put more pressure on the traditional health care delivery system in terms of increased need for extra resources and expertise has created an urgent need for the institutionalization of traditional health services countrywide. For a long time, the development and promotion of traditional health service has been negatively affected by the fact that the practice has been implicated with the existence of witchcraft and low desire of western trained health professionals to join the practice (lack of common vision and understanding between keys players; policy makers, researchers, and practitioners of both modern and traditional). This situation has led to low capacity to carry out serious research in the traditional health care system. Consequently, most research carried out in the country does not appear to be sufficiently guided to inform policy makers about traditional health management system. As such, key decisions are made in the absence of well-informed findings, thus resulting in policies that are unsustainable. However, promotion, research and development in traditional medicine needs to be focused in four major areas; product, practitioner, practices and facilities so as to guide formulation of sustainable policies.

• Traditional medicine product needs to be standardized and value and to meet the required quality.

• Practitioners of both modern and traditional needs to be oriented on traditional medicine to make them appreciate its used in health care delivery systems.

• The intellectual rights of traditional health practitioners and researchers needs be protected to enhance their participation in research.

• Practices of traditional medicines needs be opened up for better

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accessibility by the consumers and this can only be possible through the well organinized and planned traditional health facilities.

• Organized facilities will also facilitate easy interaction between traditional and modern health care practitioners.

The implementation of these areas will enhance the institutionalization of traditional health services in country. In order to promote and facilitate evidence-based decision-making among policy/decision makers, the Ministry will encourage traditional model research system through formulation of traditional model research guidelines. In pursuit of quality traditional health service delivery to clients, the MoHSW has prepared an Operational Strategic Plan which is aimed at enabling the Ministry to critically examine and identify areas that are core to its mandate, and to direct the available limited resources to areas where most impact is foreseen. The Plan aims at institutionalizing traditional medicine services and enforcement of regulations and set standards. It provides for promoting safe practice, adherence to the codes of ethics and conducts and set laws, regulations, guidelines and standards by traditional health practitioners through introduction of training modules to traditional health practitioners (healers & TBAs) and researchers, medical and paramedical students in the training institutions. In pursuance of this goal, the Council and coordination at the district level will be strengthened to oversee adherence to the standards.

4.11 Non Communicable Diseases The burden of diseases due to Non Communicable Diseases (NCD) including Diabetes, Cardiovascular diseases, Cancers, Nutritional Disorders, Injuries, Mental Health and Substance Abuse, is increasing while the health sector is less prepared to meet the evolving demands compared to communicable diseases. In addition to health promotion and prevention of NCD, curative management of these conditions at all levels has to be improved. Treatment and rehabilitation skills of NCD, among Staff in primary care facilities are very limited. RHMTs CHMTs and

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local government leaders and the community in general have inadequate awareness of the seriousness of these disorders in the community.

4.12. Neglected Tropical Diseases. Neglected Tropical Diseases (NTD) includes Onchocerciasis Lymphatic Filariasis, Schistosomiasis, Soil Transmitted Helminthes and Trachoma. Onchocerciasis is present in 7 areas of the country, putting approximately two million people at risk11. As regards, lymphatic filariasis (LF) rapid mapping indicates that the whole country is endemic. The coastal region is suspected to bear the highest burden of disease, with prevalence rates of up to 45%, as found on Mafia Island. Onchocerciasis and Lymphatic Filariasis overlap in all the onchocerciasis-endemic regions, and there has been some success in integrating the respective interventions, particularly in the Tanga region in the north-eastern part of the country.

The predicted prevalence of Soil Transmitted Helminthes (STH) is between 20-49% in most of the country, with some areas predicted to be over 50%. The problem of STH overlaps with all the other diseases. School age children are the most affected and therefore control efforts target this group. A national de-worming program for children under 5 has been integrated into the current Vitamin A supplementation program implemented through twice yearly since 2004. Tanzania has maintained Vitamin A supplementation and de worming coverage of approximately 90% since the start of the Child Health Days.

Schistosomiasis on the other hand, has a predicted prevalence of over 50% in over half of the country, particularly in the six regions around Lake Victoria and Tanganyika, the five coastal regions as well as Zanzibar and Pemba. As with STHs, the greatest disease burden is among school children. The Ministry collaborates with the Ministry of Education and Vocational Training in prevention, control and treatment of the disease. Drug treatment with Praziquantel and Albendazole has administered to 11 endemic regions in the country in 2005 by the MOH, in partnership with the Schistosomiasis Control Initiative (SCI). Active trachoma is endemic in 43 districts (prevalence >10%) in Tanzania, with prevalence rates as high as 64% in some districts. Control efforts follow the WHO-endorsed SAFE strategy (Surgery for in-turned eyelids,

11 National Onchocerciasis Control program, National Strategic Plan Draft Document 2006-2010, MOHSW

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Antibiotics for active disease, Face washing to prevent infection, and Environmental change as another preventive measure). Control measures also include distribution of Zithromax through the support of the International Trachoma Initiative (ITI).

4.13. Environmental Health Services The environmental health status in the country is far from being adequate. Although latrine coverage is 97.3% in urban and 83.3 in rural areas, it is only 52.8% of these latrines are permanent and can be recognised as fulfilling health requirements. In schools only 36.7% of all schools have adequate toilets and 20% of waste generated from health facilities is hazardous and is not properly managed. The impact of poor environment can be seen in poor households manifested by the prevalence of communicable diseases and poor health status of the people particularly the children and women. Improved environment gives rise to improved health status of the people through, for example, environmental cleanliness, provision of adequate safe water, proper waste management, safe food, improved community and personal sanitation and hygiene, improved housing and occupational health. Environmental sanitation and hygiene issues can rightly be tackled to improve the current poor environment at district and village level by building up the capacity of the environmental health delivery system in terms of increasing the number of qualified personnel; putting in place guidelines and procedures supported by appropriate legislation and enhancement of community involvement and adherence to sanitation and hygienic principles.

4.14. Advocacy Advocacy is a communication process geared at influencing behaviour towards a specific desired change. As a communication process advocacy not only informs people but also encourages new life initiatives and behaviours. People act, adopt new practices and form new life habits because of information/messages that show them how they can benefit. Thus, effective advocacy creates sense of ownership and demand for better services especially when communicated benefit is realised. Advocacy has been going on since independence with main objective of combating three enemies namely ignorance, poverty and diseases. Advocacy for disease control has been focusing on providing knowledge and skills at all levels of service delivery on various interventions including behavioural change. However, the advocacy has been centred around the national and council levels. The thrust is to go beyond the council level. This will enable the community at grass root level realise

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their roles and responsibilities in the improvement and achievement of better health services. MMAM initiative is no exception. Its success leans strongly on the involvement and active participation of all partners in health and stakeholders. The purpose of Advocacy component for MMAM is thus to encourage public support and alliances with stakeholders at all levels by ensuring high level comprehension of MMAM, its operations/ implementation and expected outcomes in line with the National Health Policy. 4.15 Institutional Arrangement The implementation of MMAM will be at all levels from National to Villages with each level having its own roles and responsibilities. This will also include modalities of implementation, feedback systems, supervision, monitoring and evaluation. The existing administration hierarchy will be used in the whole process of implementation. The following are the roles and responsibilities of different levels;

4.15.1 Ministry of Health & Social Welfare The Ministry will be responsible for formulating policy guidelines and strategies for implementation of the program; take the lead in resource mobilization for the successful implementation of the programme; Support Regional Secretariat to build capacity of LGAs in the implementation of the program; Monitor, Review and evaluate the program in collaboration with other stakeholders; Overall coordination of program activities by ensuring quality and adherence to guidelines and regulations. The Ministry will oversee the implementation of the program in collaboration will PMO-RALG. The coordination of the program activities will be done by Technical Working Group under the DPP appointed by the Permanent Secretary of the Ministry of Health and Social Welfare in collaboration with PMORALG. The Technical working group will also be responsible for planning of activities, monitor the procurement process in line with the programme implementation plan, over see the construction rehabilitation of health facilities and other technical issues. The Technical Working group will report the implementation status to the Steering Committee which is co-chaired by the permanent secretaries of the MoHSW and PMO-RALG

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4.15.2 PMO-RALG. The role of PMO-RALG is to oversee the proper functioning of the regional and district hospitals, health centres, dispensaries and community level health services. More specifically PMO-RALG will be responsible for ensuring that LGAs prepare plans and budget for the programme, resource allocation to Regional Secretariat and LGAs level. The ministry will also supervise the implementation of the programme at LGAs level. The Ministry will collaborate with the MoHSW in implementation of the programme.

4.15.3 Regional Level The regional secretariat through RHMT will provide technical and advisory support to the LGAs in order to ensure proper implementation of the programme. More over the RS will ensure that the programme is incorporated in the CCHP and budget as well as supervising programme implementation. The RS should crate a conducive environment for the implementation of the programme.

4.15.4 Local Government Level. The Local Government Authorities level (councils) will be responsible for the management, implementation, recruitment and position of technical support to the lower level health facilities. They are also required to assure that the programme is incorporated into the CCHP community participation and other stakeholders in the programme. Further more LGAs will submit both technical and physical implementation reports on regular basis maintain data bank and create awareness to the community on health seeking behaviour.

4.15.5 Ward Level The Ward through Ward Development committee (WDC) will be responsible for allocating land for the construction of a Health Centre and also supervise the MMAM implementation at their respective areas of jurisdiction. This will include coordination of MMAM activities at village level. The WDC will also work hand in hand with village Government in mobilizing communities to contribute voluntary labour and materials for the programme. Moreover, the WDC will be responsible for compiling financial and technical reports from lower levels with respect to the accepted format and submit to the Council.

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4.15.6 Village Level. The Village Government will be responsible for allocating land for the construction of a dispensary. Other duties include community mobilization for the program in terms of voluntary labour and materials, plan and implement MMAM, to create a conducive environment for the implementation of the programme and attractive working conditions for the health staff, safety in terms of buildings, medical supplies and medicines and overall supervision of the programme.

The programme will enhance and strengthen community involvement and participation in planning and implementation. To ensure sustainability and create sense of ownership of the investment, the community will participate in the management of health facilities through CHSBs and Health Committees at Health facility levels.

4.15.7 Responsibilities of Council Health Services Board and Health Facility Committees

4.15.8 Council Health Services Board Through an instrument for establishing Council Heath Service Board, the Community will continue to be involved in the management of health services and overseeing implementation of health development plans in the council. The Council Health Services Board will oversee implementation of health services within their area of jurisdiction. Council Health Management Teams (CHMTs) is a technical arm to the board and it’s the one charged with responsibilities of day to day management of health services in the district. The Board will work hand in hand with the council in mobilizing and managing all resources for the successful implementation of MMAM.

4.15.9 Health Facility Committees In every council, there are health facility committees at all levels of health care provision. The communities are involved and participate in management of health services. With respect to MMAM the health facility committees will be responsible for the following: Mobilizing resources for the implementation of the MMAM at local level, mobilizing communities to contribute in terms of voluntary labour and materials, to give feedback to the communities on the status of implementation, and to ensure safety and conducive working environment for health workers.

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INSTTUTIONAL ARRANGEMENT FOR THE IMPLEMENTATION OF MMAM.

LOCAL GOVERNMENT AUTHORITIES (LGAs)

TECHNICAL WORKING

GROUP

COUNCIL HEALTH

SERVICES BOARD

HOSPITAL GOVERNING COMMITTEE

REGIONAL SECRETARIAT

WARD WARD HEALTH COMMITTEE AND

HEALTH FACILITIES

COMMITEES

VILLAGE/STREET VILLAGE HEALTH

COMMITEE

NATIOANAL LEVEL (National Steering Committee)

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4.16. Health Care Financing There are two major categories of sources of financing in Government Health Facilities and Institutions. These are on Budget Sources and Off-Budget Sources. On budget sources include revenue from central government as well as grants and loans from development partners. The budget estimate for health expenditure includes specific votes and sub votes, for MOHSW, PMO-LARG. On the other hand off-budget sources include revenue raised from cost sharing mechanisms and councils own sources. Cost sharing funds are often included in CCHP but not consolidated into the national budget estimates. Public funding of the health sector has increased in recent years, both in nominal and real terms. The allocation to priority items has increased, notably to drugs and supplies, and to preventive and district health services. How ever the share of Government budget is 11%, still far short of Abuja Declaration target of 15% of government spending. The government introduced complementary financing schemes to complement the government efforts of financing health care services. These include user fees, drug revolving fund, National Health insurance fund for formal sector, and community health fund for informal sector.

In 1993 user fees were introduced at consultant and regional hospitals, there after use fees were rolled over to district level hospitals in January 1994. Moreover charges were introduced through revolving fund at hospital level in 1999. The National Health Insurance fund (NHIF) was established in 1999, began its operations in 2001, and currently covers all public servants both at central and local Government levels together with up to 5 other family members. NHIF is funded through a 3% employee payroll deduction matched by Government contribution. The scheme has a defined benefit package, and members are free to access services at any accredited facility of their choice. Government facilities are automatically accredited, while faith- based private providers have to conform to the MOHSW standards. The scheme is administered independent body answerable to the MOHSW; administration costs are limited by law to 8%. Benefits of the scheme include assurance of access to services for members, a shift in attitude from apathy ownership, and competition between providers resulting in improved quality.

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CHF is a voluntary pre-payment scheme which enables a household to pay premium when they have funds rather than at the time of illness, with members entitled to access curative and preventive services in primary health facilities. Revenues generated from premium are matched by a grant from the government. Those members of the community not willing to join the prepayment scheme participate in the CHF by paying a user fee when they visit a health facility for any chargeable service. Funds collected from premiums and user fee are managed by the Council Health Services Board and health facility committees. The CHF was piloted in Igunga district in 1996. There after was rolled over to nine more districts. In 2001, the policy decision was reached to cover all districts and is taken as one of the conditions to extend cost sharing in primary health care facilities. To date 72 districts are practicing CHF. Benefit package of the scheme include all services at primary heath care. CHF members have a choice of a health provider to which they have a confidence of expected better services. The uses of CHF fund include purchase of additional drugs, supplies and rehabilitation of health facilities. The community identifies the poor and is exempt them. The council issues a health card to the identified poor families so that they can access health care services in their respective health facilities. This scheme is considered to have the potential of ensuring greater security of access to health care, empowering households and communities in health service management decisions and promoting partnership and local participation in health care financing. The three health financing options; user fees, Community Health Fund and National Health Insurance have the potential of raising 15.4 billion Tshs. per annum. More than 92% of this amount which accrues to the Regional and District health facilities is at the discretion of the facilities and health administration to be used for development of health services including financing of activities under this programme.

4.17. Monitoring and Evaluation Monitoring and evaluation of MMAM is designed to ensure effective and efficient implementation of plan of action and the sustainability of the intended outputs and outcomes. Monitoring will involve tracking the progress of the plan of action, while evaluation will be a critical and objective appraisal of the overall implementation of MMAM at all levels

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5.0 COMPONENT OBJECTIVES AND STRATEGIES. 5.1 Human Resources for Health

5.1.1 Objectives Human Resources for Health • Expand training intake for increased output • Train and acquire adequate tutors • Recruitment and deployment of adequate skilled health workers • Improve health workers competence • Promote incentive initiatives/package for health workers with

emphasis to those working in the difficult areas • Establish new training program for most needed cadres

5.1.2 Strategies • To cover the shortage of 68% of human resource for health, an

additional workforce will be required through the following strategies to be implemented in 5 years:

- Introduce an incentive package that will attract health workers to work in difficult and remote areas

- Device workplace programs that will retain health workers. - Reduce attrition of health workforce - Technical Assistance by using consultants in specialized fields - Provide adequate essential medicines, medical supplies,

reagents. -

5.2 District Health Services: 5.2.1 Objectives

• Rehabilitation, construction and upgrading of 5720 primary health care facilities, 62 district hospitals and 128 training institutions, including construction of new training institution by year 2017

• To strengthen 2,555 health centres by constructing theatres and providing them with necessary medical equipment and furniture by year 2017

• To strengthen 62 District Hospitals by Construction of Emergency Obstetric Care (EMOC) Theatres complete with medical equipment, plant and furniture by 2017

• To assess the capacity of the training institutions to absorb increased future enrolment

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• Rehabilitation, construction and upgrading of 128 Training Institutions including equipment, furniture and training materials by 2017.

• To provide equipment, medical equipment, furniture and plants in 7,783 health facilities by 2017

• To strengthen outreach services by providing 2574 ambulances, 140 supervision vehicles, 114 mobile clinics to all districts and 2,555 motor cycles to all health centres by 2017

• To strengthen communication systems to all 114 Districts by 2017 • To ensure availability of essential medicines, medical supplies and

equipment in public primary health facilities at affordable cost • To promote efficient and effective management of medicines, medical

supplies and equipment in primary health facilities • To provide anti-TB and anti-leprosy drugs in all eligible health

facilities by 2017. • To provide medicines and medical supplies for prevention and

treatment of non – communicable and neglected tropical diseases. • To strengthen referral system from dispensary to district hospital

5.2.2 Strategies • Deployment and recruitment of appropriate skilled personnel • Ensure availability of drugs, supplies, equipment • Rehabilitate existing health facilities to be able to provide additional

services having additional rooms to ensure privacy • Construct new health facilities with necessary skilled health providers • Provide mobile clinics for outreach services • Ensure adequate allocation of budget for medicines and medical supplies in

public primary health facilities to ensure constant availability of essential medicines, supplies and equipment at affordable cost.

• Improvement of delivery system and management for provision of medicines, supplies and equipment in public primary health facilities.

• Ensure availability of guidelines in primary health facilities to promote rational use of medicines, medical supplies and equipment

• Establishment of planning and standardized stock-control systems for medicines Procurement and maintenance of vehicles and ambulances to all district hospitals and health centres based on the standard guidelines of the Ministry of Health and Social Welfare by year 2017.

• Construction, expansion, and rehabilitation of dispensaries in various sites based on the standard guidelines of the Ministry of health and Social Welfare by year 2017. Provision of equipment, furniture and plants to selected health centres and dispensaries by year 2017

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5.3 Maternal, Newborn and Child Health

5.3.1 Objectives • To reduce maternal mortality from 578 to 175 per 100,000 live births

and under five mortality from 112 to 45 per 1000 live births by 2017 • To increase coverage of births attended by skilled attendants from 46%

in 2004 to 88% by 2017

5.3.2 Strategies • Capacity building for Maternal, Neonatal and Child interventions for

service providers and pre service tutors • To scale up essential child health interventions to reach every child • Recruitment and deployment of skilled providers to the existing and

new health facilities. • Increase intake of students in allied health institutions (Nurse Mid

wives, AMOs, CO, Anaesthetists, Laboratory technicians) • Strengthening health system for quality improvement of maternal,

newborn and child care at all levels of implementation • Procurement of Essential Equipment, supplies for maternal, newborn

and child health implementation. • Renovation and building operating theatres , labour wards, neonatal

wards, RCH Clinics, including staff houses • Procurement and distribution of radio calls and ambulances to be

stationed in selected health facilities(hospitals , health centres) in each districts

• Behavioural change communication • Advocacy for maternal, newborn and child health at all levels • Community mobilization and empowerment

5.4 Malaria

5.4.1 Objectives; To reduce the burden of Malaria by 80% by the end of 2017 from current

levels.

5.4.2 Strategies • Case Management and Malaria in Pregnancy • Integrated Malaria Vector Control

- Re introduction of Indoor Residual Spray - Environmental Management

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- Laviciding - ITNs

• Malaria epidemics • Information Education and Communication/ Behavioural Change

Communication • Operational Research. • Monitoring and Evaluation • Program Management and Coordination

5.5 The National AIDS Control Programme 5.5.1 Objectives • To increase and strengthen services for the care and treatment of people

living with HIV/AIDS to reach 1,800,000 by 2017. • To implement a comprehensive HIV prevention interventions and increase

access to services for the prevention of mother to child transmission of HIV in all health facilities providing reproductive and child health services by 2017.

5.5.2. Strategies

• To scale up access to ART stepwise from tertiary, secondary centres to potentially include district health facilities, Health centres and dispensaries in the context of training, establishing and strengthening these services and drug availability by end of 2017.

• To evaluate the progress of the training and scaling up of ART services. • To scale up down to the district level, involving communities through

home-based care using lessons learned in the first years of implementation of care and treatment in the country.

5.6 Tuberculosis and Leprosy

5.6.1 Objectives • To reduce prevalence and death rates associated with Tuberculosis by

50% from current levels by 2017 • To eliminate leprosy as a public health problem in the country from

1.2 to below 1 case per 10,000 population by 2017

5.6.2 Strategies • Political commitment with long-term planning, adequate human

resources, expanded and sustainable financing • Improve the scope and quality of DOTS

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• Raise awareness among community members on TB and leprosy diseases

• TB management through quality-assured diagnosis (microscopy, culture and drug sensitivity testing) and standardized treatment

• An effective and regular drug supply with improved management capacity

• Scaling up screening of TB and HIV/AIDS co-infected patients and coordination

• Establish services for the management of drug-resistant tuberculosis • Equitable access to TB and leprosy services for all people, especially

the poor and marginalized • Strengthen leprosy elimination campaigns and PoD activities in the

country • Improve TB and leprosy management information system to

accommodate TB/HIV surveillance and gender disaggregating

• An efficient monitoring system for programme supervision and evaluation including impact measurement

5.7 Neglected Tropical Diseases

5.7.1 Objectives To reduce the burden of Neglected Tropical Diseases until they are no longer of public health significance at all levels by 2017

5.7.2 Strategies • Implementation of the SAFE strategy, in managing trachoma which

encompasses the following key elements; Surgery to correct advanced stages of the disease; Antibiotics to treat active infection and interrupt the cycle of

infection; Face washing to reduce disease transmission; and, Environmental change to increase access to clean water and

improved sanitation. • Strengthening school health programme in combating schistosomiasis. • Strengthening and expansion of Lymphatic Filariasis Control Program

(LFCP • Strengthening and expansion of National Onchocerciasis Control Program.

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5.8 Non Communicable Diseases

5.8.1 Objectives • To improve service provision for control and prevention of non

communicable diseases at primary levels of health care delivery.

5.8.2 Strategies • Capacity building of health care providers at primary facility

levels • Community involvement in the control of NCDs using relevant

IEC. • Involvement of other stakeholders in the control and

prevention of NCDs

5.9 Environmental Health and Sanitation

5.9.1 Objectives To strengthen environmental Health, Sanitation and Hygiene services.

5.9.2 Strategies • Capacity building for environmental officers at district and ward level • Strengthen community participation in hygiene and sanitation

interventions

5.10 Health Promotion and Education

5.10.1 Objectives • To build capacity for communities and individuals to engage in health

promotion and education activities at all levels

5.10.2 Strategies Support all program components to enhance behaviour change for informed health choices and action Promote advocacy for primary health care services and mobilize resources for the program Build capacity on Health promotion & education/communication to all stakeholders. Promote community involvement and participation in health activities

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5.11 Nutrition

5.11.1 Objectives To build capacity for Nutrition interventions at district and community

levels

5.11.2 Strategies Development and recruitment of nutrition focal personnel

5.12 Traditional and Alternative Medicine

5.12.1 Objectives • To facilitate the provision of quality traditional and alternative medicine

services to all people to enable them improve their wellbeing. • To Promote (standardization and formulation of value added traditional

medicine products through the application of )Traditional Model Research and development

• To establish and strengthen registration of traditional health practitioners • To Institute Quality Assurance Programmes and Certification of

Traditional Medicine Products

5.12.2 Strategies • Promotion of the establishment of modern traditional medicine facilities. • Promoting (standardization and formulation of value added traditional

medicine products through the application of )Traditional Model Research and development

• Promoting Documentation of the traditional and alternative medicine services

• Instituting Quality Assurance Programmes including certification of Traditional Medicine Products

• Promoting local production and safe use of traditional and alternative medicines

• IEC and advocacy of traditional and alternative medicine • Develop standard guidelines, monitoring and evaluation Strategies

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5.13 Public private partnership

5.13.1 Objectives To strengthen and promote private sector participation in the implementation of PHSD programme.

5.13.2 Strategies • The government will regularly review monitoring systems and

jointly develop, with private providers, guidelines for monitoring of private health services.

• The government will promote and facilitate regular partnership meetings to strengthen and sustain public-private partnership initiatives as part of the implementation arrangements.

5.14. Advocacy for PHSDP

5.14.1 Objectives: To advocate understanding of PHSDP to stakeholders at all levels

5.14.2 Strategies: • Awareness creation • Community involvement and participation

5.15 Institutional Arrangement.

5.15.1 Objectives: To strengthen PHSDP management and coordination capacity of MoHSW and PMO-RALG

5.15.2 Strategies Put in place a coordination mechanism with clear terms of reference for the implementation of PHSDP within MoHSW and PMORALG.

5.16 Health Care Financing

5.16.1 Objectives • To mobilize additional resources to supplement the Governments efforts

for implementation of the programme. • To allocate sufficient funds to support MMAM implementation by

Government, Development Partners, NGOs/CSOs, and Private Sector.

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5.16.2 Strategies: • Strengthen existing complimentary financing schemes such as NHIF, CHF

and User fees. • Mobilisation of sufficient funding from within and without.

5.17 Programme Monitoring and Evaluation

5.17.1 Objectives • To monitor the programme implementation progress based on set targets • To conduct mid and end of the programme evaluation

5.17.2 Strategies • Creation of an institutionalized programme management structure at

various levels • Strengthen the capacity of the central MoHSW/PMORALG, RS/RHMTs

and Council/CHMTs to undertake effective programme supervision of planned activities

• Plan for programme evaluation

Page 70: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Primary Health Services Development Programme ____________________________________________________ 56

6.0 LOGICAL FRAMEWORK

6.1 Annual Activity Targets The attached Annex 1, physical implementation summary shows the outputs.

6.2 Financial Outlays The attached Annex 2, financial outlays shows the resource requirements.

Page 71: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Primary Health Services Development Programme ____________________________________________________ 57

ANNEXES

ANNEX 1: ANNUAL ACTIVITY TARGETS ANNEX 2: FINANCIAL OUTLAY ANNEX 3: ACTION PLAN FOR PHSDP

Page 72: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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Page 79: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 80: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 81: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 82: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

lth S

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Page 83: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 84: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 85: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 86: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 87: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 88: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 89: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Page 90: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 91: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 92: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

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Page 93: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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Page 94: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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Page 95: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Page 96: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Page 97: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Page 98: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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Page 99: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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Hea

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Page 100: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Incr

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Esta

blis

h H

BC

se

rvic

es in

5 to

10

faci

litie

s pe

r dis

trict

fr

om 8

0 di

stric

ts to

90

dist

ricts

Esta

blis

h H

BC

se

rvic

es in

5 to

10

faci

litie

s di

stric

t fro

m

90 d

istri

cts t

o 10

5 di

stric

ts

Esta

blis

h H

BC

se

rvic

es in

5 to

10

faci

litie

s dis

trict

fr

om 1

05 d

istri

cts

to 1

20 d

istri

cts

Esta

blis

h H

BC

se

rvic

es in

5 to

10

faci

litie

s dis

trict

fr

om 1

20 d

istri

cts

to 1

27 d

istri

cts

Incr

ease

nu

mbe

r of

patie

nts o

n A

RT

from

70

,000

to

150,

000

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ease

nu

mbe

r of

patie

nts o

n A

RT

from

15

0,00

0 to

20

0,00

0

Incr

ease

nu

mbe

r of

patie

nts o

n A

RT

from

20

0,00

0 to

30

0,00

0

Incr

ease

num

ber

of p

atie

nts o

n A

RT

from

30

0,00

0 to

45

0,00

0

of p

atie

nts o

n A

RT

from

45

0,00

0 to

60

0,00

0.

To

impl

emen

t of

co

mpr

ehen

sive

H

IV p

reve

ntio

n in

terv

entio

ns

and

incr

ease

ac

cess

to

serv

ices

for t

he

prev

entio

n of

m

othe

r to

child

tra

nsm

issi

on o

f

Incr

ease

co

vera

ge o

f PM

TCT

serv

ices

fr

om th

e cu

rren

t 12%

to

20%

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ease

co

vera

ge o

f PM

TCT

serv

ices

from

20

% to

30%

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ease

co

vera

ge o

f PM

TCT

serv

ices

from

30

% to

40%

Incr

ease

cov

erag

e

of P

MTC

T se

rvic

es fr

om

40%

to 5

0%

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ease

cov

erag

e

of P

MTC

T se

rvic

es fr

om

50%

to 6

0%

Page 101: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

____

____

____

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pone

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Prov

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ledg

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H

IV/A

IDS

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n,

care

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tr

eatm

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o th

e co

mm

unity

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ide

know

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H

IV/A

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care

and

tr

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e co

mm

unity

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ide

know

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H

IV/A

IDS

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care

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tr

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e co

mm

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IDS

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are

an

d tr

eatm

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e co

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unity

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are

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d tr

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mm

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25%

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ses

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with

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4hrs

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ons

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ver

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fev

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case

s tr

eate

d w

ithin

24h

rs

of o

nset

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feve

r

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feve

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ses

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ted

with

in 2

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of

ons

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65%

feve

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ses

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ted

with

in

24hr

s of

ons

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f fe

ver

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ses

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with

in

24hr

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f fe

ver

H

IV in

all

heal

th f

acili

ties

prov

idin

g re

prod

uctiv

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d ch

ild h

ealth

se

rvic

es b

y 20

17

T

UB

ER

CU

LO

SIS

AN

D

LE

PRO

SY

To

redu

ce

prev

alen

ce a

nd

deat

h ra

tes

asso

ciat

ed b

y T

uber

culo

sis

by

50%

by

2017

Con

duct

su

rvey

to

esta

blis

h m

agni

tude

an

d de

aths

du

e to

tu

berc

ulos

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C

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agni

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aths

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tube

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C

ondu

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urve

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ablis

h m

agni

tude

and

de

aths

due

to

tube

rcul

osis

Page 102: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

____

____

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__

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T

rain

500

in

-ser

vice

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alth

w

orke

rs

(nur

ses,

cl

inic

al

offi

cers

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ctor

s an

d la

bora

tory

te

chni

cian

s)

in T

B a

nd

lepr

osy

cont

rol

Tra

in 1

,000

in-

serv

ice

heal

th

wor

kers

(n

urse

s,

clin

ical

of

fice

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doct

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labo

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tech

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in

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Tra

in 1

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nici

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le

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Tra

in 1

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heal

th

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kers

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rses

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inic

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ffic

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do

ctor

s an

d la

bora

tory

te

chni

cian

s) in

T

B a

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pros

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l

Tra

in 1

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in-

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ice

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th

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kers

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rses

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inic

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do

ctor

s an

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bora

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chni

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T

B a

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pros

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l

In

trod

uce

inte

grat

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TB

and

H

IV/A

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serv

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in

30 c

ounc

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Intr

oduc

e in

tegr

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TB

an

d H

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0 C

ounc

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oduc

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tegr

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TB

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d H

IV/A

IDS

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0 co

unci

ls.

Intr

oduc

e in

tegr

ated

TB

and

H

IV/A

IDS

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in 3

2 co

unci

ls.

Impl

emen

ting

inte

grat

ed T

B a

nd

HIV

/AID

S se

rvic

es in

all

coun

cils

.

Page 103: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

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____

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__

89

Com

pone

nts

Obj

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40%

of

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mun

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mem

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kn

owle

dgea

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of

vari

ous

TB

an

d le

pros

y co

ntro

l m

easu

res

50%

of

com

mun

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mem

bers

kn

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dgea

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of

var

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TB

an

d le

pros

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easu

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60%

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kn

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of

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bers

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of

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res

Page 104: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

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evel

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rogr

amm

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____

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30

% o

f al

l pu

blic

and

pr

ivat

e he

alth

ce

ntre

s an

d ho

spita

ls

have

ca

paci

ty to

pr

ovid

e qu

ality

di

agno

sis

of

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clud

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drug

re

sist

ance

an

d su

cces

sful

ly

trea

t 85%

of

patie

nts

40 %

of

all

publ

ic a

nd

priv

ate

heal

th

cent

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and

hosp

itals

hav

e ca

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ty to

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nce

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ly

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e ca

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agno

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ly

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t 85%

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all p

ublic

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d pr

ivat

e he

alth

ce

ntre

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spita

ls h

ave

capa

city

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qual

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nosi

s of

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100

% o

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l pu

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he

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and

ho

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ls h

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s of

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clud

ing

drug

re

sist

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and

su

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eat

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patie

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To

elim

inat

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pros

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a p

ubli

c he

alth

pro

blem

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the

coun

try

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2 to

bel

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ca

se p

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pula

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by

2017

Con

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le

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Con

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dist

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s

Page 105: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

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ent P

rogr

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____

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NO

NC

OM

MU

NIC

AB

LE

D

ISE

ASE

S

To

impr

ove

serv

ice

prov

isio

n fo

r co

ntro

l an

d pr

even

tion

of

non

com

mun

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le

dise

ases

at

prim

ary

leve

ls

of

heal

th

care

del

iver

y.

Dev

elop

IE

C

mat

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ls o

n N

on-

com

mun

ica

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ases

Tra

in P

HC

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med

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or N

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mun

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Tra

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EN

VIR

ON

ME

NT

AL

HE

AL

TH

SE

RV

ICE

S

Env

iron

men

tal

Hea

lth

Ser

vice

s (S

anita

tion

and

hy

gien

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or

prev

entio

n an

d co

ntro

l of

com

mun

icab

le,

non

com

mun

icab

le,

emer

ging

and

re-

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dis

ease

s in

the

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mun

ity

stre

ngth

ened

by

2017

.

Vill

age

gove

rnm

ent

s in

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Cou

ncils

ha

ve

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ed

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are

enfo

rcin

g E

nvir

onm

enta

l Hea

lth

By-

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s

Vill

age

gove

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ents

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all C

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nvir

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ealth

By-

Law

s

Page 106: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

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ent P

rogr

amm

e __

____

____

____

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____

____

____

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____

____

____

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92

Com

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H

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to

hous

e in

spec

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an

d co

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unity

pa

rtic

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in h

ygie

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and

sani

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ca

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t in

3,0

00.

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ho

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insp

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Hou

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Hou

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ards

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Page 107: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

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Hea

lth S

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evel

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____

____

____

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____

____

____

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en

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n ne

w

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n ne

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mpe

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ed

in d

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3 r

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ard

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reng

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in d

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in 7

re

gion

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ed

in d

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ard

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l st

reng

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ed in

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stri

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in

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gion

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s co

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ed in

al

l dis

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HE

AL

TH

PR

OM

OT

ION

A

ND

E

DU

CA

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N

To

build

ca

paci

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or

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d in

divi

dual

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in

heal

th

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of

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45

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f th

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65 %

of

the

70

% o

f th

e

10%

of

the

Page 108: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

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evel

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amm

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____

____

____

____

____

____

____

____

____

____

____

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com

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TR

ITIO

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build

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paci

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or

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ritio

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terv

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stri

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nd

com

mun

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l

20 D

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cou

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istr

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crui

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ater

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tr

aini

ng

coor

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tr

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onal

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edic

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in

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in

trad

ition

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in

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AD

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DIC

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e pr

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ativ

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trai

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aine

es o

n tr

aditi

onal

m

edic

ine

Page 109: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

____

____

____

__

95

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to

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trad

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med

icin

e fa

cilit

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Page 110: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

____

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96

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Page 111: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

evel

opm

ent P

rogr

amm

e __

____

____

____

____

____

____

____

____

____

____

____

____

__

97

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on p

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Page 112: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

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opm

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____

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____

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Page 113: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

Prim

ary

Hea

lth S

ervi

ces D

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ent P

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amm

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____

____

____

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Page 122: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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7

Page 123: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

All

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Page 124: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

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7

Page 125: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

All

figur

es in

000

'000

Tsh

s.

YR 1

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2004

till

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by

2017

Page 126: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

All

figur

es in

000

'000

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s.

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As,

C

OM

MU

NIT

Y

Intro

duce

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or re

sidu

al s

pray

ing

(IRS

) in

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pro

ne

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ricts

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he

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mic

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the

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urre

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All

figur

es in

000

'000

Tsh

s.

7

YR 1

YR 2

YR 3

YR 4

YR 5

YR 6

YR 7

YR 8

YR 9

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ESPO

NSI

BLE

Ann

ual B

udge

tO

BJE

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AC

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BU

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unta

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g an

d te

stin

g se

rvic

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the

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127

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985

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W, P

MO

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,RS

s,LG

As,

C

OM

MU

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Y

Pro

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STI

pre

vent

ion

and

treat

men

t ser

vice

s in

all

hea

lth

faci

litie

s

20,

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HS

W, P

MO

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,RS

s,LG

As,

C

OM

MU

NIT

Y

Pro

vide

hom

e ba

sed

care

ser

vice

s fo

r peo

ple

livin

g w

ith H

IV/A

IDS

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5

103

10

3

103

10

3

103

10

2

102

10

2

10

2

10

2

MO

HS

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MO

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As,

C

OM

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Y

Incr

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f pat

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s on

A

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's fr

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00 to

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10

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MO

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As,

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OM

MU

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Y

Pro

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vent

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of m

othe

r to

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smis

sion

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IV s

ervi

ces

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ll he

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600

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HS

W, P

MO

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ALG

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s,LG

As,

C

OM

MU

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Y

Pro

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wle

dge

on H

IV/A

IDS

pr

even

tion,

car

e a

nd tr

eatm

ent t

o th

e co

mm

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4

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,450

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0

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0

6

,200

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0

7,25

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MO

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OM

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496

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36

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Trai

n 4,

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ce h

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0

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8

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8

0

8

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MO

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OM

MU

NIT

Y

Intro

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inte

grat

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of T

B

and

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/AID

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all

dist

ricts

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0,00

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,000

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000

4,00

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,000

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0

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HS

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MO

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ALG

,RS

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OM

MU

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mem

bers

on

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rious

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HS

W, P

MO

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C

OM

MU

NIT

Y,

PAR

TNE

RS

Stre

ngth

en th

e ca

paci

ty o

f low

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l hea

lth fa

cilit

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arly

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agno

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tmen

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rral

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with

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g re

sist

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27

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250

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0

20

0

MO

HS

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MO

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As,

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MU

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To e

limin

ate

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osy

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blic

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robl

em in

th

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untry

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to

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r 10,

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latio

n by

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Con

duct

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inat

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cam

paig

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00

125,

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1

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125

,000

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1

25,0

00

1

25,0

00

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25,0

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1

25,0

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As,

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4,62

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460

129

,460

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30,4

80

13

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131

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To re

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and

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ciat

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Tub

ercu

losi

s by

50%

fro

m --

----

by 2

017

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TO

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peop

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ach

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017

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NO

N C

OM

MU

NIC

AB

LE D

ISEA

SES

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All

figur

es in

000

'000

Tsh

s.

8

YR 1

YR 2

YR 3

YR 4

YR 5

YR 6

YR 7

YR 8

YR 9

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0R

ESPO

NSI

BLE

Ann

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tO

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250

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MO

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Pro

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terv

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760

120

200

200

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Pro

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e co

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EDIC

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Page 129: THE UNITED REPUBLIC OF TANZANIA - tzdpg.or.tz · HIV/AIDS is among the main killer disease in Tanzania, whereby over two million people have been infected with HIV and thousands have

All

figur

es in

000

'000

Tsh

s.

YR 1

YR 2

YR 3

YR 4

YR 5

YR 6

YR 7

YR 8

YR 9

YR 1

0R

ESPO

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BLE

Ann

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udge

tO

BJE

CTI

VES

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