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Initially the main areas towards
achieving more comprehensive reforms in the sector were based on the findings
of the analysis of the current situation conducted in 1993-94 and grouped the
problem/ issues into: Ideological, Organizational, Managerial, and Financial
arena. From these issues the government proposed reforms that would seek to
reinforce whatever strength existed in the health care system but also lead to
improvement that will eliminate the weaknesses identified in the health sector.
These are:

3.2.1 Ideological Reforms

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The government has since independence
implemented directives given by the ruling Party at the time of one Party
system in the country; – that health services be made available free of charge
to all Tanzanians. Understandably, the directive required expansion of health
service delivery units (dispensary and health centres) mainly in rural areas as
well as designing and doubling training programmes for production of human
resource to man the units. This meant the government remained the main provider
and sole financier of health services in the country with little
supplementation by the not for profit NGOs.

Proposed Reforms

Institute ideological and conceptual
change to the public so that every Tanzanian becomes responsible for his/her
own health through taking active part in disease prevention and health
promotion, and realises that health service provision is not free of charge.

The government to change from being
sole provider of services assume the role of a facilitator and advocate for
solid partnership with Private for profit sector.

3.2.2 Organizational Reforms


The organisational issues identified
are in two folds:- Administrative
& Managerial

Administratively, each local authority (district/
council) was responsible for the running of health centres and dispensaries in
its own district/council with subventions from the central government and their
own revenues. Regional and district hospitals were administered by the Ministry
of Regional Administration and Local Government (MRALG) now PMORALG. The MoHSW
was/ is responsible for the national/referral/ specialised hospitals, health training
schools and national programmes. At the end, the MoHSW is technically
responsible for all health matters, while the management teams- RHMRs and DHMTs
were technically under the MoHSW.

This system resulted in dual
responsibilities at the district level, thus, unclear line of authority and
accountability and consequently, inappropriate utilization of manpower and
improperly functioning referral system 

Proposed administrative reform:

The proposals for health sector reform
recommended the following to address the gaps:

The government facilitate provision of
prioritised, accessible, quality, well supported, cost effective health
services in the districts within well defined government administrative
structures for the local governments;

Strengthen the referral system so that
it functions at all levels;

District Health Boards and Facility
Committees be established;

The ministry relieves itself with some
of the responsibilities and duties that could be implemented through the
professional councils, by giving them more autonomy and concentrate with its
facilitation role of policy formulation, developing guideline, legislations,
regulations, standards and control.

Managerial issue

Managerially, it was identified that, the District
Medical Officer was not the main officer responsible for health service
delivery at the district level. This in mind, coordination of health activities
in the district became an issue leading to lack of integrated health sector
planning and evaluation with consequent duplication of generic
functions/activities. Above all, planning in the sector has been ad hoc, and
driven by the availability of funds. Amazingly, the concept of decentralisation
and Primary Health Care (PHC) was not well understood by some policy makers,
implementers and community members.

Proposed Managerial reform

District health planning guideline be
developed to enable the ministry facilitate implementation of health activities
in the district and coordinate donor inputs;Capacity building to all levels in
planning, management and delivery of health services under a reformed structure
to enable them interprets and implement health related policies; 

Advocate and promote Primary health
care within the concept of inter-sector collaboration;

Health facilities are managed by the
communities in which they are located; 

2.2.3 Financial Reforms


It was identified that underfunding has
been a major problem. Budgetary constraint has never been in favour of the
government to sufficiently finance the extensive network of health facilities
in the country. The underfunding was compounded by the fact that health
expenditure was largely devoted to hospital care as a result of combination of
reasons; institutional inertia, political influence, doctors’ professional
lobbying etc. Until the mid 1990s, 57% of total Tanzanian health expenditure
was spent on curative care, 11% devoted to community and 32% to preventive care
(WB, 1997-a) Per capita expenditure on public health services by that time
(1994- 96) was about US $ 3.2 and for basic clinical services US $ 4.19
totalling 7.34 as compared to national target of US $12 .  Within the health sector it was found
personal emoluments alone were taking almost 70% of the recurrent budget
leaving only 30% of the recurrent for non salary items!  As a result, most of the facilities suffered
from shortage of essential drugs and supplies as well as deteriorating
infrastructure due to lack of adequate financing and weak management.

Proposed reform

The health sector reform strategy
planned to have additional resource mobilization and strengthening the
financing mechanisms as major priorities in ensuring sustainable
financing.  In order narrow down the
financing gap and develop a more sustainable financing mechanism for the health
sector, the government also, planned to diversify the resource base and explore
alternative ways of financing health care. To achieve this government would:

Increase health funding to not less
than 14% of her budget and develop an alternative financing options;

Review the curative services spending
in order to target resources to more cost effective services and increase
resources to preventive services

Develop different financing options
including increased private financing;- cost sharing, insurance, and private
payments; Pre testing of a community based pre- payment scheme (Community
Health Fund ) in Igunga district and roll to other districts. Prepare and
introduce National Health Insurance for civil servants and piloting of drug
revolving funds at hospitals

Revise user charges regularly focusing
on drugs and other services expenses

Develop appropriate budgeting and
accounting guidelines and provide intensive training to managers of health

Equip referral hospitals i.e. existing
consultant hospitals with relevant equipment and skills to enable them handle
cases that were referred abroad

Budget allocations to the health sector
were proposed to be based on population patterns, income distribution and
utilisation of health services.

3.2.4 Public /Private Mix Reforms


Despite its importance, the private
sector involvement in national health policy formulation has been hardly
adequate, and there has been little cooperation and coordination of planning
and delivery of health services among public, private, and voluntary agency
providers. After the Arusha declaration there had been no clear policy on
delivery of health services which favoured the private sector participation in
delivery of health services in the country.

However, with the amendment of the
Private Hospitals (Regulation) Act of 1977 in 1991, there has been mushrooming
of Private health facilities with concentration in urban areas. Above all, the
re-opening of the Private medical practice and adoption of the Trade
liberalisation policy accelerated the increase of private pharmaceutical stores
and clinics in various areas. During this period there was no reliable quality
control mechanisms in place for private pharmacies/stores, nor regulation for
traditional medical practice. The Pharmaceutical and Poisons Act of 1978 was
obviously outdated following the pace of the reforms that were gaining speed.

Reforms on Public Private Mix

It was proposed that the government
re-examine the relationship with the private sector, and create environment
that will promote sound development of the private sector while of the adequate
quality assurance and regulatory mechanisms are in place. This includes:

Amendment of the existing Legislation
on private practice to accommodate:

Clear definition of the facility being

Regular MoHSW supervision of the
practice through an inspectorate unit at central lvel and the office of the RMO
and DMO at their levels;

Different health cadres to operate
private facilities offering services such as laboratory and maternity homes;

Development of proper authority for
checks and balances of the private sector.

more efforts on the rehabilitation and consolidation of existing health
facilities and consider construction of new primary health care facilities only
when it is proved that the need of such facilities is great;


remuneration packages in the public sector in light of bringing a balance with
the packages in the private sector

3.2.5 Research Reforms


From the situational analysis, it was found that most of
the research on health issues, be it operational or biological was not demanded
by the national health system. In many cases, research are initiated and
conducted by academic institutions or outside the ministry for their own


 Proposed reform

The existing health research units –
National Institute of Medical Research, Tanzania Food and Nutrition Centre, and
the Health System Research unit at the Ministry of Health were proposed to be
strengthened with adequate resources to carry out and monitor appropriate


In this aspect, the government would
establish a health research fund within the Ministry of Health for
commissioning research whose findings would be required by the ministry.

3.2.6 Nutrition and Population


Although there have been various efforts to improve
malnutrition in Tanzania, still the levels of malnutrition remained
significantly high when compared to world standards.


Proposed reform

The Tanzania Food and Nutrition Centre
was charged to carry out programmes that would enable the country to achieve
its National Nutrition goals which were set for the year 2000 and beyond as:

To reduce severe malnutrition from the
1990 rate of 6% to 2% or less and moderate Malnutrition from 46 – 22% by the
year 2000;

Reduce the prevalence rate of low birth
weight from 14% in 1990 to less than 10% by the year 2000;

Reduce Maternal mortality rate by half
from the 1990 level of 200-400/100,000 live births to 100-200 /100,000 live
births by the year 2000;

Reduce Iron deficiency anaemia in women
by one third of the 1990 levels

Eliminate Iodine and Vitamin A
deficiency including blindness as a puplic health problem.

To empower all women to breastfeed
their children exclusively- four to six months and continue breastfeeding to
two years and beyond

Ensure care of the vulnerable groups
particularly children, pregnant and lactating women.

3.3 Conclusion:

Change is inevitable because every
individual and organization experience change, change it implies a new
equilibrium between different components of the organization structure, and
technology. Changing process need a competence manager to influence change in
an organization Amana hospital was successful due to the leadership style with
the competence manager who has the abilities and qualities to influence change
also the use of technique to overcome resistance to change all these facilitate
positive changes in the hospital. Through DHIS2 there is improvement in the way
of reporting also unnecessary delay of sending the report to DMO is eliminated,
generally there is a great improvement and achievement in the hospital due to
the change which has taken place.


3.4 Recommendations:

Manager should be open and explain to
the employees the need for change, also should explain how change will be
beneficial to all, not only that but manager should create the environment for
the change to take place Example procure of enough computers to all department
so as to make equipment available for the employees to do their work in a
comfortable way hence successful to the organization. However participatory and
involvement of employees to the changing process it is very important so as to
overcome resistance to change, ongoing training is also important since change
is the process therefore there is a need for the manager to provide ongoing
training to the employees so as to increase their skill and knowledge in the
use of computer.


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