Tanzania, situated on the eastern side of Africa, is a country faced with major challenges. Internal factors such as poor infrastructure, low education levels, poverty, and diseases exacerbate the extent of these challenges. The bold attempt, in the form of the Millennium Development Goals (MDG) set by the United Nations (UN), to eradicate poverty, mortality, and combat diseases remains important for countries striving to improve the overall state of wellness of their societies.
An essential part of and what can be considered threshold conditions for any country’s economic and social development is ensuring that its population has access to adequate health care services and facilities. Only half of the population (54%) has access to improved drinking water, while only 24% has access to improved sanitation facilities.
As such, maternal mortality, child mortality, HIV/AIDs, pneumonia, and malaria, are major issues that the health system faces, with malaria being the most common. Given the disease profile of this country, it appears that based on the most pressing health challenges (malaria and HIV/AIDS), prevention and health promotion are the greatest health service needs. This clearly supports a more active role for dispensaries and hospitals who could assist in carrying the more preventive and health-care-promotion.
The Tanzanian health system is decentralized and framed most explicitly by its National Health Policy. The Tanzanian National Health Policy appears to be driven primarily by the objective to provide access to quality primary health care for all citizens. Explicitly linked to the health-related Millennium Development Goals (MDG) is the policy’s identification of and focus on resources towards an essential health care package, which is “an integrated collection of cost effective interventions that address the main diseases, injuries and risk factors” in the country. Community health promotion and disease prevention through environmental sanitation and management of occupational health services is recognized as a key component.
In general, the health services are heavily based on national government financing, with some tax-based funds through local government council tax collection and other earnings. The Community Health Fund (CHF) is viewed as an effective “tool for mobilizing voluntary community involvement and participation in supporting their own health,” whereas the Health Insurance Scheme is seen as a “mechanism to ensure medical protection of employees in the formal sector.”
Regardless of the context within which health care has to occur, fundamental to ensuring the health of the nation is the availability of appropriate numbers and quality health dispensaries.
Tanzania has a population of over 43 million people with a majority under the age of 18. There has been a steady slowdown in the population growth rate from 7.5% (in 1970 – 2009) to 4% (2000 – 2009). Socio-economic factors such as poverty and increasing cost of living and education levels are assumed to have contributed to the decline in population rates. The population continues to be overwhelmingly rural, with only 26% of its populace residing in urban areas.
The country’s land area is 945 km2, and is very arable and mountainous in the North east where the World Heritage site Mount Kilimanjaro is situated. There are great lakes known for their unique fish species. Tanzania, Mozambique, and Zambia share water resources in terms of lakes. Lake Victoria is shared to the north with Uganda and Kenya, Lake Tanganyika with Zambia, Burundi, and the Democratic Republic of Congo, and Lake Nyasa is shared with Malawi and Mozambique. Tanzania is divided into 26 regions – 21 on the mainland (for instance, Dar es Salaam, Kigoma, Kilimanjaro, and Mwanza) and 5 in Zanzibar (Zanzibar North, Zanzibar Urban/West, Tanga, etc). Tanzania has a tropical climate, where in the highlands, temperatures range between 10 and 20 degrees Celsius while the rest of the country remains hot and humid with temperatures rarely falling below 20 degrees. There are 2 major rainfall periods between October to December and March to May. This climate of course, impacts the specific disease profile in the country, and presents the ideal environment for the high prevalence of malaria.
Within these regions, there are 98 districts, each with at least one council, created to increase local authority. There are 114 councils with the majority of these operating in rural and only 22 in the urban areas. Dares Salaam is the largest city and is the commercial capital. Dodoma, located in the center of Tanzania is the new capital and houses the unions and parliament.
There have been multi-party elections since 1995, although there is only one dominant political party – Chama Cha Mapinduzi. The president and the national assembly are elected concurrently by direct popular vote for a 5 year period. The president selects cabinet ministers and the constitution allows the president to nominate non-elected members to the national assembly. They have passed laws that ensure that women hold positions in the national assembly. The judicial system has 5 levels combining tribal, Islamic, and British common law. Judges are appointed by the Chief Justice of Tanzania, except those for the Court of Appeals and the High Court who are appointed by the President. Under the leadership of Julius Nyerere, the socialist government focused heavily on achieving social equity through the development of strong health and education sectors. These policies were, however, unsustainable, given the realities of an economic crisis and negligible growth.
The country’s colonial legacy has had an impact on the extent of inequality still experienced by the majority of Tanzanians today. For instance, while some peasants were connected to the cash crop export economy, others were not, resulting in some of the populace living relatively comfortably in urban areas in comparison to the vast majority in rural areas, which does not.
The population of Tanzania consists of people of African, Arab, Indian and Pakistani origin and a small Chinese constituency, with the majority on the mainland and some in Zanzibar. There are over 120 African ethnic groups, of which the Sukuma and Nyamwezi have over a million members, and their origins include the nomadic Maasai and Luo groups. These 120 ethnic groups have their own languages but the Sandawe groups speak languages of the Khoisan family.
Although Swahili is the official national language, after gaining independence, it is commonplace for English to be used alongside it. English is not conventionally used in administration or parliament, but in the court of law, it is still the de facto official language. The primary schools mostly teach in Swahili, whereas English is the language of choice for universities where people exclusively use it to communicate with each other.
It is estimated that roughly one third each of the population is Muslim, Christian and have indigenous religious beliefs. The Christian believers mostly consist of Roman Catholics, Protestants (Lutheran), Pentecostals and Seven Day Adventists. The Christians are mainly found inland, while almost all Muslim communities are concentrated in the coastal areas of Zanzibar. Other religious groups, such as Buddhists and Hindus can also be found.
Tanzania’s economy has been performing better in recent years but the majority of people continue to live below the poverty line, and it is thus not surprising for it to be classified as a low-income country. The economy is mostly based on agriculture, accounting for over half of the Gross Domestic Product (GDP), and the sector employs almost half of the working population. Cultivated land is approximately 4% of the land area. The country is abundantly supplied with natural resources such as commodities and natural gas.
An essential part of and what can be considered threshold conditions for any country’s economic and social development is ensuring that its population has access to adequate health care services and facilities.
The population’s access to water and sanitation is an indication of the extent to which the populace might be exposed to unsanitary and disease-prone instances, and can be used to assess the baseline state of health. It is clear that access to clean, drinkable water and sanitation prevents to a large extent the exposure to common diseases.
To assess the major problems in a country’s health system, the typical starting point is the indicators associated with life and death. The rates of mortality and fertility are also used as proxies to indicate the degree of development in a country, in comparison to others. In Tanzania, the general fertility rate (total births per woman) in 2009 was 5.5%. Positively, the general life expectancy has risen from 51 years in 1990 to 55 years in 2009, but this is still substantially lower than the global average (68 years).
Vast numbers of women die (the majority of which are preventable deaths) every year, related to complications during or resulting from pregnancy and birth. Maternal mortality, closely related to the right to the highest attainable standard of health, is the outcome generally used to assess progress towards improving maternal health. Tanzania’s 2008 maternal mortality rate (790 per 100 000 live births) is shocking in that it represents almost 3 times the global average and is roughly 1/4 more than that experienced in the region.
Further related is the issue of child mortality. Although the child mortality rate is almost double that of the global average, it is positive that there has been a decline between 1990 and 2009 (162 to 108), as well as for the infant (99 to 68) mortality rate during the same period. The leading cause of child deaths, of those children who survive the neonatal period, continues to be the consequences of preventable diseases, including malaria, pneumonia, diarrhea, malnutrition, complications arising from low birth weight, and HIV/AIDS. More than 70% of a staggering almost 11 million child deaths every year are attributable to the following highly preventable causes: diarrhea, malaria, neonatal infection, pneumonia, pre-term delivery, or lack of oxygen at birth.11 When we examine the distribution of causes of death in children under the age of 5 in Tanzania (2008), malaria and pneumonia (both 16% of deaths) are ranked a combined first, followed by diarrhea (13% of deaths) as the second most common. It is encouraging that over half (close to 57%) of children under the age of 5 are receiving anti-malaria drugs (2008) but there are still too many who remain untreated.
For adults, HIV/AIDS continues to be the leading cause of death. Between 2005 and 2009, the percentage rate of prevention among young people who have comprehensive knowledge of HIV illustrates the extent of inequalities still evident between men and women, with the rate for men (42%) being higher than that for women (39%). Anti-retroviral treatment coverage for people with advanced HIV infection in 2008 was a very low 14%.12 Most recently, the Iringa recorded the highest rate of HIV/AIDS prevalence at 14.7% (previously 13.4%) followed by Dar es Salaam at 8.9% (previously 10.9%), Mbeya at 7.9% (previously 13.5%) and Shinyanga at 7.6% (previously 6.5%). Zanzibar had the lowest prevalence rate at 0.6%. In terms of age, the highest prevalence is amongst the 35-39 age group (10%) (Tanzania Affairs, 2009). Table 5 indicates that the HIV prevalence of Tanzania is substantially higher (7 times) than the global average.
It is encouraging that the country’s TB prevalence is 15% lower than that of the global average, and also represents a decline from the 2006 figure (187). Perhaps more importantly, the death rate from TB has declined since 2006 (13); and the 2009 figure represents 6.5% of 2009 TB prevalence, while the treatment success rate recorded in 2008 is at 88%.
As the health policy describes, the major challenge that “the people of Tanzania suffer most from [is] acute febrile illness caused by malaria, [while] the groups most vulnerable… are young children and pregnant women.” The overall prevalence of malaria in young children in Tanzania is at 18%. The great inequalities in the country are again illustrated in a big disparity between this rate in the rural and urban areas. In rural areas, 20% of children carried the malaria parasite compared to 7% in urban areas. Thus, although HIV and TB are important, malaria is acknowledged as the biggest health problem in Tanzania and it is concerning that its prevalence has remained virtually static between 2002/3 and 2004/5 (decreasing only from 40.9% to 40.1%).
Given the disease profile of this country, it appears that based on the most pressing health challenges (malaria and HIV/AIDS), prevention and health promotion are the greatest health service needs. This clearly supports a more active role for our dispensary/hospital, which could assist in carrying the more preventive and health care.