THE UNITED REPUBLIC OF TANZANIA
PROGRAM FOR RESULTS
MATERNAL AND CHILD HEALTH SERVICES INVESTMENT
PROGRAM (P170435)
DRAFT
Prepared by the World Bank
May 2022
1
Technical Assessment
A. Program Description
1. The government program in mainland Tanzania is anchored in the Health Sector Strategic Plan V
(HSSP 2021/22 – 2025/26) and comprises Primary Health Care (PHC) services, regional referral hospitals
and referral services while the PforR Program comprises essential maternal and child health (MCH)
services at the PHC level, selected regional referral hospitals, and activities to strengthen referral services
at district and regional levels. The operation is primarily focused on MCH services, but also covers health
systems functions pertinent to improving provision and quality of MCH services, including human
resources for health; performance and functionality of health facilities; referral services; management,
organization, and institutional arrangements; and community health services. The PforR Program will
support five Key Result Areas: (i) maternal and child health services; (ii) human resources for health; (iii)
emergency and referral services; (iv) health facility performance and functionality; and (v) management
and accountability functions. The five Key Results Areas (KRAs) are aligned with the four HSSP V strategic
directions: (a) provision of health services; (b) organization of health services; (c) health system
performance; and (d) health system investments and functioning. The scope of the proposed program
includes recurrent and operating costs, goods, small works, and services.
B. Description and Assessment of Program Strategic Relevance and Technical Soundness
B.1 Strategic Relevance
2. Over the last two decades, Tanzania has improved coverage of selected high impact interventions,
registered improvement in population health outcomes, and reduced the disease burden, which dropped
from 88,225 to 41,047 disability adjusted life years (DALYs) per 100,000 population between 2000 and
2019.1 Over the same period, life expectancy increased from 51 to 65 years while under-five mortality and
infant mortality dropped from 148 deaths and 98 deaths per 1,000 live births to 67 deaths and 43 deaths
per 1,000 live births, respectively.2 These improvements are attributed partly to the control of major
communicable diseases including vaccine preventable diseases, diarrheal diseases, malaria, and HIV/AIDS,
and management of maternal and child health conditions including integrated management of childhood
illnesses. While Tanzania has made progress, its disease burden remains high. Communicable diseases,
maternal, neonatal, and nutritional disorders remain major drivers of mortality and illness for the
population. Neonatal disorders are the third key driver of the disease burden with newborn mortality rate
of 27 deaths per 1000 live births. Maternal mortality ratio has stagnated at about 530 deaths per 100,000
live births in mainland Tanzania. The high total fertility rate (TFR, 5.2 per woman) together with early
marriage and childbearing among adolescent girls are among the factors that partly drive the high
maternal mortality. Moreover, stunting is persistently high affecting 34 percent of children under five
years of age. (Table 1 in Annex 1)
3. A large share of maternal deaths is attributed to poor obstetric care. Lack of competent and skilled
staff,3 and problems with anesthesia, equipment, and blood and its products are some of the limitations
1Instituteof Health Metrics and Evaluation (IHME), Global Burden of Disease, University of Washington.
2Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015/16
3 The 2020 Service Availability and Readiness Assessment shows that only 56% of the facilities could screen for anaemia and only
63% had dipstick to measure protein in urine. This is concerning because anaemia is the third leading cause of maternal deaths in
Tanzania.
2
in the provision of obstetric care. With regards to deaths among under-5 children, about 102,0004 die
each year, out of which 66 percent are neonates. The main causes of deaths among under-5 children in
Tanzania are pneumonia (14 percent), intrapartum (14 percent), preterm (11 percent), congenital (9
percent), and diarrhea (8 percent). At the current rate of progress, Tanzania is unlikely to achieve the
health-related sustainable development goals. Most of these conditions are preventable and manageable
using available cost-effective interventions, and unless Tanzania turns the tide against communicable
diseases and maternal and child health conditions, it risks a prolonged dual disease burden due to the
already high burden of the non-communicable diseases. For example, between 2000 and 2019, about 57
percent of deaths among under-5 children were prevented because of increased vaccination coverage.5
It is further predicted that increased vaccination coverage and introduction of new vaccines would result
in a 72 percent reduction in lifetime mortality among under-5 children by 2030.6 Scaling-up
implementation of the integrated management of childhood illnesses (IMCI) strategy for under-5 children
is also associated with reduced under-5 mortality. A meta-analysis of IMCI studies from Bangladesh, India
and Tanzania show that under-5 mortality can be reduced by 13 percent if the IMCI strategy is
implemented.7 Evidence also shows that about one-third of maternal deaths can be prevented by scaling-
up family planning services which could delay motherhood, avoid unintended pregnancies and
subsequent abortions.8
4. Tanzania is prone to periodic disease outbreaks. Besides the COVID-19 pandemic, Tanzania lately
experienced outbreaks of anthrax, cholera, and dengue fever. As of May 6, 2022, Tanzania has reported
a cumulative total of 33,928 confirmed cases and 803 deaths since March 2020 and witnessed disruptions
in uptake of pentavalent vaccine, admission of children under five years, and management of cases with
severe malaria including IPT2 during ante natal care.9 To ensure continued delivery of essential health
services during the COVID-19 pandemic and beyond, the government, in response introduced a new pillar
on maintaining essential health services as part of the COVID-19 National Response Plan (2021-2022) with
the aim of (a) mapping services to identify gaps in service delivery; (b) sustaining delivery of quality of
essential health services; and (c) monitoring and coordination of essential health services during the
pandemic and beyond.
5. The Human Capital Index (HDI) for Tanzania is low, and in 2020 was estimated at 0.39, which is
below its expected level of development, and places it among the bottom 35 countries globally. Despite
the decline in the poverty rate, the absolute numbers of the poor increased from 12.3 million in 2011 to
about 14 million in 2018 because of the high population growth rate, and a large share of the population
remains vulnerable and risks falling back into poverty. In 2018 almost half the population was living below
the international poverty line of US$1.9 per day. There is recognition that without improving the health
of the population, Tanzania will not realize the aspirations enshrined in Vision 2025 and improve its
human capital. There is a strong justification for government intervention and public financing of essential
PHC services as a large share of the population, especially the poor rely on these services. In this respect,
4 Sharrow et al (2021). Levels and Trends in Child Mortality: Estimates by the UN Inter-agency Group for Child Mortality
Estimation. UNICEF: New York.
5 Li, X., et al. (2021). Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income
countries from 2000 to 2030: a modelling study. The Lancet, 397(10272), pp.398-408.
6 ibid
7 Gera et al. (2012). Integrated management of childhood illness (IMCI) strategy for children under five: Effects on death, service
utilization and illness. Cochrane Database of Systematic Reviews, (9).
8 Collumbien et al. (2004). Non-use and use of ineffective methods of contraception. In: Ezzati M, Lopez AD, Rogers A, Murray CJL,
editors. Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors.
Geneva: World Health Organization: p. 1255–320. PMID
9 World Health Organization (Tanzania) Maintain or restore the provision of essential health services during Covid-19 pandemic in
the United Republic of Tanzania. April 11, 2022
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health is considered essential for economic development and poverty reduction in Tanzania and has been
identified as a priority in (i) the Government’s Tanzania Development Vision 2025 (launched in 1999); (ii)
the National Development Plan (2021/22-25/26); and (iii) the World Bank’s Country Partnership
Framework (CPF, Report No. 121790-TZ, FY18-22). Strengthening capacity to provide PHC services and
improving maternal and child health services are among the key priorities outlined in the various
documents for Tanzania to improve the health of its population.
B.2 Technical Soundness
6. The Program Development Objective (PDO) is to scale-up provision and improve quality of
essential primary health care services with a focus on Maternal and Child Health (MCH) Services. To
achieve the objective, the Program will strengthen capacity to (i) deliver essential PHC services,
particularly those related to reproductive, maternal, neonatal, child, adolescent health and nutrition
(RMNCAH-N) and quality of care, and (ii) provide referral services as part of the continuum of care.
7. The Program’s focus on improving delivery and quality of essential health services with particular
emphasis on RMNCAH-N at the primary health care level is appropriate. Physical access to health facilities
alongside coverage of essential health services has significantly improved in Tanzania.10 However,
Tanzania has had limited success with improving quality of care and provision of emergency obstetric
care, newborn care, family planning, essential emergency and referral services and nutrition services.
Coverage of essential services for newborn care including signal functions is limited: according to the
Demographic Health Survey (DHS, 2015), only 47 percent of mothers reported at least two of the six signal
functions were performed during childbirth.11 Likewise, 81 percent of 53 hospitals and 15 percent of 152
health centers sampled could perform all the signal functions for comprehensive emergency obstetric
care with 32 percent of health centers able to provide blood services.12 Treatment coverage of children
with severe acute malnutrition remains low with only 12 percent receiving adequate management.13
8. Low quality of care is a major impediment to improving health service delivery. The specific
guidelines, while available in most health facilities, are not routinely applied. The stepwise star rating
quality assessment of health facilities in 2018 rated 20 percent of health facilities 3 stars and above and
identified gaps with (a) staffing, (b) management of emergencies and referrals, (c) clinical support services
(laboratories and medicines), and (d) facility infrastructure.14 Poor quality of health services not only
represents inefficient use of resources, as seen with overcrowding of hospitals with patients requiring
primary health care services, it also hinders provision of appropriate emergency and referral services,
especially to those needing critical care as part of the continuum of care. In general, referral services are
weak, plagued with coordination challenges, and most health facilities are unable to manage basic
medical emergencies (obstetric or newborn resuscitation) including the treatment of the critically ill
patients.
9. In addition to gaps in the quality and coverage of RMNCAH-N services, the key bottlenecks
towards improving provision of essential health care services identified under the Program reflect
challenges with (a) production and management of the health workforce; (b) performance and
10 Ministry of Health. Annual Health Sector Performance Report (2020)
11 The six signal functions are cord examination, temperature measurement, counseling on danger signs, counseling on breast
feeding, observing breast feeding, and weighing the baby.
12 Service Availability and Readiness Assessment (SARA, 2020).
13 Midterm review of the National Multisectoral Nutrition Action Plan (July 2016 –June 2021)
14 The star rating assessment tool assesses quality of service delivery of health care facilities and rates them on a scale of one to five
stars.
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functionality of the health facilities; (c) referrals and management of emergencies; and (d) management
and accountability functions. These bottlenecks summarized below are derived from the Health Sector
Strategic Plan V (2021-2026), Human Resource for Health Strategic Plan (2020–2025) and the National
Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child, and Adolescent Health
(2020 - 2025) and were informed by the mid-term reviews of the previous plans in 2019. These
bottlenecks fall within the remit of Ministry of Health (MoH) and President’s Office, Regional
Administration and Local Government (PORALG) and Tanzania could realize major gains by tackling them
more effectively.
10. Human resources for health (HRH) are an important resource for the delivery of health services,
and unless the persistent HRH challenges are effectively tackled, it is unlikely Tanzania will be able
improve provision and quality of health services, especially for frontline services. Countrywide, there is
an overall staff shortage of 52 percent with dispensaries (69 percent). (Table 2) Recent recruitment efforts
have not managed to bridge the gap, and staff density remains unchanged owing to the growing
population and continued health infrastructure expansion.15 These challenges are further compounded
by shortcomings in pre-service training and competence gaps in clinical practice. Besides shortages of
critical cadres, many training programs lack qualified tutors, use outdated and inappropriate curricula
unable to provide competence-based training.16
Table 2. HRH Need versus Availability in 2019
Facility Levels Required Available Shortage Available % Shortage %
Dispensary 99,060 30,625 68,435 30.92% 69.08%
Health Centre 32,487 17,954 14,533 55.27% 44.73%
District Hospital 21,600 17,443 4,157 80.75% 19.25%
Other Hospital* 26,400 11,243 15,157 42.59% 57.41%
Regional Hospital 14,226 11,373 2,853 79.95% 20.05%
National, Zonal, Specialized 14,509 10,349 4,160 71.33% 28.67%
and Referral Hospital
Health Training Inst. 1,321 697 624 52.76% 47.24%
Grand Total 209,603 99,684 109,919 47.60% 52.40%
* This category includes voluntary agency hospitals
Source: Human Resources for Health Strategic Plan 2020-2025
11. Many health facilities operate below the designated standards for their level.17 While the overall
capacity of health facilities to provide general health services increased from 57 percent in 2017 to 69
percent in 2020, the overall capacity is still low with services for emergency obstetrics and newborn care
considerably much lower.18 This challenge reflects weaknesses with management and coordination of
health facility infrastructure investments which are made without provision of complementary inputs
including staffing, medical equipment and supplies. In recognition, the government under the HSSP V is
committed to addressing gaps in the functionality of the PHC facilities to ensure the facilities are not only
ready, but able to provide the requisite services.
15 MoHCDGEC, HSSP IV mid-Term Review Report 2019; For Zanzibar, the ratios are 0.95 physicians per 10,000 population and 4.65
nurses per 10,000 population
16 Human Resource for Health Strategic Plan 2020–2025
17 Ministry of Health. Annual Health Sector Performance Profile (2019)
18 Service Availability and Readiness Assessment (2020)
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12. Measures to improve referrals both for emergency and non-emergency cases have had limited
success and continue to hinder efforts to improve quality of care in Tanzania. While 32 percent of health
facilities had arrangements for emergency transportation in the rural areas, only 24 percent of urban
health facilities had such arrangements.19 The majority of district and referral hospitals are crowded with
primary patients and are ill prepared to respond to emergencies rendering hospitals unable to provide
the essential critical care services as part of the continuum of care. Furthermore, the current referral
system is plagued by coordination challenges. A study on the pattern of referrals by referral hospitals
revealed that 35 percent of all referrals were preventable with the most common reasons for referrals
related to staffing, equipment, and drugs or supplies including blood.20 Improving referrals and
management of emergencies is recognized as a priority and many pilot initiatives are on-going, which
government intends to adapt and roll out countrywide in a phased manner.
13. Mainland Tanzania has continued to devolve management of health services delivery to the Local
Government Authorities (LGAS) and PHC facilities including rolling out Direct Health Financing Facility
(DHFF) to the PHC facilities. While many of the structures and systems have been elaborated these need
to be strengthened for health facilities to adequately plan, manage, and report on their performance.
Among others, it is necessary to strengthen (a) capacity of PHC facilities to coordinate community-based
health services within their catchment populations, (b) facility governance arrangements, (c)
management functions at the health facilities including scaling up use of electronic management
information systems and measures to promote accountability for service delivery, and (d) measures to
ensure compliance with technical as well as fiduciary (procurement and financial management) standards
and practices.
14. Based on the defined bottlenecks, the Program identified five Key Result Areas (KRAs) with direct
causal links corresponding to the major bottlenecks affecting delivery of health services at the PHC level.
The KRAs are geared towards improving provision and quality of RMNCAH-N services at the PHC and
improving performance and ensuring functionality PHC facilities and referral services as part of the
continuum of care. Instead of relying on the approach whereby technical programs individually manage
their investments, the Program is expected to contribute to better coordination and management of the
investments at the PHC facilities. Through this approach, the health facilities will be able to deliver the
appropriate complement of the essential health services, which entails ensuring general service
availability and readiness of the PHC facilities to provide essential and quality services. The Program’s
KRAs - (a) maternal and child health services; (b) human resources for health; (c) emergency and referral
services; (d) health facility performance and functionality; and (e) management and accountability
functions are further explained below.
15. The KRA on maternal and child health services aims to consolidate implementation of existing
RMNCAH-N services and to scale up the services where Tanzania had had limited progress at the PHC
level. Besides emergency obstetric care, newborn care, where the least progress has been made, will
receive greater priority with PHC facilities expected to deliver the essential services and perform the basic
signal functions for newborn care. In addition, the PHC facilities will be supported to adopt continuous
quality improvement initiatives, oversee the volunteer community health workers (CHWs) and network
with schools in providing adolescent health services. Guidelines to this effect are to be developed by
PORALG. The activities under the KRA will be financed though the Health Basket Fund (HBF), and plans
developed and monitored as part of the Comprehensive Council Health Plans (CCHP) with the Council
Health Management Teams (CHMTs) being responsible for supporting and supervising the PHC facilities.
19 Tanzania Service Availability and Readiness Assessment (2020)
20 Jumbam et al. BMC Health Services Research (2020) 20:725 (https://doi.org/10.1186/s12913-020-05559-x).
6
By channeling funds through the HBF, the Program will leverage funding from other partners and benefit
from arrangements put in place by government and the HBF partners to monitor implementation of HBF
financed programs. The KRA will be assessed based on the performance of the LGAs, and central and
regional entities against a set of indicators comprising RMNCAH-N services delivery indicators and health
systems strengthening indicators targeted towards improving quality of care.
16. The KRA on HRH is aimed at improving availability of skilled health workers at the primary health
care level and selected regional referral hospitals. The interventions address the persistent challenges
affecting management of the HRH and include: (i) recruitment and equitable deployment of health
workers with a focus on PHC health facilities; (ii) training of cadres in short supply (both clinical and
nonclinical) through short and long-term courses; (iii) strengthening capacity of selected health training
institutions to conduct competency-based trainings; and (iv) clinical mentorship, coaching and
attachment of newly recruited health workers. The government will prepare specific plans for the
implementation of the activities over the Program’s duration. Clinical mentorship, coaching and
attachment will be adapted from the ongoing initiatives in the country implemented in collaboration with
other partners. Through these interventions, besides improving staff availability, Tanzania will improve
management practices to enhance staff productivity.
17. Management of emergencies and referral services is a major gap, and under this KRA, the
Program will: (i) enhance capacity of PHC health facilities and selected regional referral hospitals to handle
referrals and emergencies including managing critically ill patients in accordance with established
standards and (ii) establish reliable systems for communication and transport to coordinate and manage
referrals between communities, PHC facilities and regional referral hospitals. Based on the several
ongoing pilot initiatives on referrals in the country, the government will develop a model
strategy/program customized at the regional level for adoption and implementation in a phased manner
by the RRHs and PHC facilities including district hospitals. The system is envisaged to include an electronic
dispatch system. At present, there is no coordinated referral system in Tanzania. Once in place the system
will benefit non RMNCAH-N patients and will assist in the establishment of a coordinated referral system
for the country.
18. The result area on improving performance and functionality aims at ensuring selected PHC health
facilities achieve the recommended service delivery standards. For dispensaries this means performing
signal functions for basic obstetric emergency, while for health centers and district hospitals performing
signal functions for comprehensive obstetric emergency. To this effect, PORALG will develop a plan
detailing the actions to improve performance and ensure functionality of the selected PHC facilities. In
addition, this KRA will support measures to mainstream continuous quality improvement initiatives,
adoption of quality-of-care practices, and implementation of the homegrown star rating assessments to
monitor performance of PHC facilities. Building on the lessons from previous implementation, the star
rating assessment will be simplified, digitized, and revised to incorporate a module to assess clinical
practices at the PHC facilities. In addition, the recently introduced clinical audits will be rolled out in the
regional referral hospitals and district hospitals. The MoH will prepare and circulate appropriate
guidelines.
19. Finally, the last KRA on management and accountability will strengthen management and
oversight functions at the PHC health facilities, RMNCAH-N coordination functions at all levels, and
management and coordination functions for the Program. Particular attention will be given to
strengthening fiduciary capacity of the LGAs and the PHC health facilities and implementation of the
selected capacity building activities necessary for execution of the Program.
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20. In summary, the proposed Program is technically sound, and the design takes into consideration
the respective mandates of the key entities involved in its execution. The Program is adequately
structured with clear linkages between Program activities and the results. It focuses on the key challenges
facing delivery of essential health services at the PHC level in Tanzania and is geared to improving quality
of care and scaling up provision of evidence-based and cost-effective RMNCAH-N interventions. In
addition, the Program will contribute towards Tanzania’s COVID-19 response by strengthening capacity
to maintain the delivery of essential health services. The Program builds on local as well as global
experiences including the last Program, Strengthening PHC for Results (P152736).
B.3 Institutional Arrangements
21. There are adequate governance and coordination arrangements in place at the national, regional
and LGA levels to implement the Program. The MoH and PORALG will oversee implementation of the
PforR Program in line with their respective mandates. Both MoH and PORALG have coordination
arrangements with each other and other stakeholders including development partners through the
existing technical working groups. In addition, the Program will use the coordination mechanisms for the
HBF whereby partners and government meet quarterly to review implementation of PHC services. A
Steering Committee will also be established between the key implementing agencies to provide
implementation oversight.
22. In accordance with the decentralization strategy, subnational Program activities will be carried
out by the government institutions at regional and local government as well as health facility levels. The
Council Health Management Teams (CHMTs) working under the Local government Authorities (LGAs) are
responsible for coordinating the delivery of PHC services and will oversee implementation of Program
activities at the LGAs. The CHMTs report to the District Council. The Program activities will be included in
the respective Comprehensive Council Health Plans (CCHPs) prepared by the LGAs. The CCHPs include
health facility plans approved by Health Facility Governing Committees (HFGCs). At the health facilities
(public, faith-based, and private), the HFGCs are charged with overseeing implementation of the health
facility plans. For the regional referral hospitals, hospital managers together with relevant Hospital
Services Boards oversee operations of the hospitals. To facilitate referral services, the respective regional
referral hospitals will liaise with the surrounding LGAs to establish appropriate mechanisms for referrals.
C. Description and Assessment of Program Expenditure Framework
23. After contracting in 2020, Tanzania’s economy is expected to recover in the medium term; but
stay fragile due to the COVID-19 pandemic and prevailing external factors.21 The real GDP growth rate is
projected to reach 4.5–5.5 percent in 2022 and average about 6 percent over the medium term as exports
and domestic demand recover. Per capita GDP growth for 2021 is estimated at 1.3 percent, before
accelerating to 2.9 percent in 2022. Although exports have increased, Tanzania’s current account deficit
is projected to widen to 3.7 percent of GDP in 2022 due to rising imports. Public spending rose from 16.4
percent of GDP in 2019/20 to 18.6 percent in 2020/21 and the fiscal deficit is projected to widen to 4.2
percent of GDP in 2022, driven by pandemic-related public spending and the implementation of several
major capital projects.22 In 2020, inflation reached 3.7 percent, and is expected to stay below 5.0 percent
in the medium term. The value of nominal public debt-to-GDP ratio was estimated at 40.6 percent in
2020.
21 World Bank. Tanzania Economic Update March 2022, Issue 17
https://www.worldbank.org/en/country/tanzania/publication/tanzania-economic-update-teu
22 Over the period, development expenditures increased from 6.5 percent of GDP to 8.2 percent, while recurrent expenditures
rose from 9.9 percent of GDP to 10.4 percent.
8
24. Health is among the priority sectors in Tanzania, coming behind infrastructure and education.
Compared with general government expenditure, health spending has grown at a much lower rate. Over
the last several years, the share of public spending on health in relation to total public spending has been
declining from 9.3 percent in 2013/14 to 7.4 percent in 2021/22. The budget allocation accounted for 1.5
percent of Gross Domestic Product (GDP), down from and 1.8 percent, respectively over the same period.
The downward trend in the share of health spending is explained by increased government spending on
the implementation of several flagship capital projects.
25. Overall, total health expenditures increased by an average of 5.2 percent between 2010 and 2017.
Over the same period, total per capita expenditure increased from US$23.6 to US$28.5, while government
per capita expenditure increased from US$ 7.7 to US$11.6. Under the current scenario, Tanzania’s per
capita health spending falls far below the recommended US$86 required to achieve universal health
coverage. Furthermore, external funding represents a significant share of public health spending (60
percent) with a large proportion (85 percent) being off budget. According to the 2019/2020 National
Health Accounts, household health expenditures were estimated at 28 percent of total health
expenditures. In addition to committing to reversing the drop in government funding to the health sector,
the government has prepared a bill to expand social health insurance as its key strategy to achieve
universal health coverage. Tanzania attained middle income status in 2019 and has the fiscal capacity to
reverse the decline and sustain the increase in domestic financing for health in relation to general
government spending.
Table 3. Financing Sources of Government Public Health Expenditures (Percentage)
2017/18 2018/19 2019/20 2020/21 2021/22
Budget Expenditure Budget Expenditure Budget Expenditure Budget Expenditure Budget
Government 61% 63% 55% 60% 41% 35% 50% 39% 57%
Foreign 22% 13% 24% 16% 34% 33% 30% 35% 22%
...Basket 9% 8% 6% 5% 6% 7% 3% 4% 5%
...Non-Basket 13% 6% 18% 12% 28% 27% 27% 31% 17%
National Health
Insurance Fund 13% 23% 16% 23% 21% 30% 16% 23% 18%
Community
Health Fund 1% 0% 4% 1% 4% 1% 2% 2% 2%
User Fees 3% 1% 1% 0% 1% 1% 1% 1% 1%
26. Tanzania has a well-established structure of planning and budgeting, both at the central and
decentralized levels. A Public Expenditure Review (PER) process is conducted every year to assess the
consistency of the approved budget and actual public expenditures against the government policy priority
objectives and helps with fiscal policy formulation and management. In addition to audit reports by the
Controller Accountant General (CAG), the MoH with support of partners regularly undertakes National
Health Accounts (NHA) and resource tracking and mapping for the health sector. Together, these
processes can provide a comprehensive review of the expenditure framework of the Government’s
program on primary health care. Over the Program’s duration, the conduct of NHAs and resource tracking
and mapping is to be institutionalized within the MoH, which will ease generation of the necessary
information relevant for reviewing budgetary performance, resource flows and spending in the sector.
27. With respect to budgetary composition, the largest share of the health sector’s budget in FY
2019/20 went to salaries at 33.5 percent, followed by institutional capacity building at 31.8 percent and
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curative services at 7.1 percent, while prevention and control of communicable diseases was allocated
3.7 percent (Figure 1).23 The low allocation to prevention and control of communicable diseases reflects
significant off budget spending on the area. For FY 2019/20, recurrent budget and development budget
stood at 59.2 percent and 40.8 percent, respectively.
Figure 1: Key Budget Allocations by Institutional Objectives of MoH (FY 2019/20 as a
share of total budget of MoH)
Salaries
23.9% Institutional Capacity of Ministry to Implement its Core Functions
33.5%
3.7% Provision of Curative Services improved
7.1%
Prevention and Control of Communicable and non-Recurrablediseases
31.8% and Neglected tropical Diseases Improve
Source: Ministry of Finance and Planning, Budget book 2019/20 Volumes 2, 3 and 4 and Supply Votes (Ministerial)
28. The LGAs receive on average between 50 percent and 60 percent of health sector’s budget in the
country through �?scal transfers from the central government (Figure 2). Based on available data, in FY
2021/22, 66 percent of the health budget allocated to LGAs was on recurrent items, including salaries and
29 per cent for development purposes. With respect to the cost centers, the largest share of the LGA
budget on health in FY 2021/22 was allocated to dispensaries at 49 percent, followed by council
administration at 19 percent and health centers at 18 percent, while council hospitals and voluntary
agency hospitals were allocated 14 percent and 1 percent respectively (Figure 3). It is worth noting that,
the high allocation to administration reflects budget allocation to on the salaries for the entire LGA level.
Figure 2. Share of Budgets and Expenditures by Level
100%
80% 45%
55% 56% 57% 58% 57% 59% 66%
60% 73%
40%
20% 45% 44% 43% 42% 43% 41% 55%
27% 34%
0%
Expenditure
Expenditure
Expenditure
Expenditure
Budget
Budget
Budget
Budget
Budget
2017/18 2018/19 2019/20 2020/21 2021/22
Central LGA
Figure 3. LGAs Budget allocation by Cost Centers
23 Health Budget brief 2020, mainland Tanzania UNICEF
10
Council Administration
19% (CHMT)
49% Council Hospital Services
14%
18%
1% Voluntary Agency Hospital
Health Centres
29. In Tanzania, there are three budget line items: Personnel Emoluments (PE), Other Charges (OC)
and Development (Local and External). All non-salary recurrent spending is within the OC. Fund flows to
LGAs from domestic resources are transferred directly from Ministry of Finance and Planning (MoFP) as
(i) PE block grants and (ii) recurrent health block grants (LGA level OC). In addition, part of OC allocations
through external financing is sent to LGAs and PHC facilities (from HBF) directly from the MoFP under the
Direct Health Financing Facility (DHFF), while medicines allocations which are transferred as goods instead
of cash from Medical Stores Department to LGAs are channeled via the MoH. LGAs also receive own-
sources revenues through user fees, National Health Insurance Fund (NHIF) and Community Health Fund
(CHF) but given low enrollment in the NHIF and CHF programs and high level of exemptions, these
represent a small share of health spending (Table 3). HBF funds are allocated using an allocation formula
that include a combination of capitation and output indicators. Furthermore, the NHIF and the improved
Community Health Fund now pay facilities directly. These reforms are encouraging as they constitute a
shift away from input-based allocation toward a system that finances outputs, which can incentivize
health providers to improve utilization and quality of health services.
30. With the introduction of the Direct Health Facility Financing (DHFF), PHC facilities gained formal
recognition as public spending entities and now have individual Charts of Accounts (COA) which gives
individual facilities the opportunity to prepare their own plans and budgets. In addition, the FM systems
were enhanced through development of a Facility Financial Account and Reporting System (FFARS) to
manage and report expenditures at primary health facilities. Despite these efforts, prioritization of the
budget towards MCH services remains a challenge. Building on the ongoing efforts, the Program will
support interventions geared towards harmonizing financial management information systems at the PHC
facilities as well as planning and budgeting to enhance greater emphasis on MCH and quality
improvement interventions.
31. Budget execution in the health sector has been lower compared with the national budget
performance, with significant underperformance in relation to the development budget financed both by
local and foreign sources. While budget execution in the health sector improved from 54.5 percent in FY
2017/18 to 71.6 percent in FY 2018/19, this was still much lower compared with 87 percent and 79
percent for the national budget for the same period. Budget performance for foreign-financed
development was estimated at 59.9 percent, while the rate for locally financed development budget was
estimated at 43.4 percent in 2018/19. Late releases and procurement challenges are the main reasons for
the underperformance. In addition, geographic inequality in the distribution of grants including DHFF
among the LGAs remains substantial. In both 2018/19 and 2019/2020 69.5 percent and 67.9 percent of
the LGAs had their per capita expenditure below the average across all LGAs of US$2.05. The significant
variances in per capita health sector allocations are also seen with the regions. For instance, Geita region,
the health budget per capita was TSh 8,570, which was less than the regional average of TSh 13,437. It
11
must be highlighted that, disparities in the allocation of resources to LGAs are significantly affected by the
availability of health facilities and medical personnel.
32. The scope of the proposed Program includes recurrent and operating costs, goods, works and
services.24 Project expenditure framework aligns to government budget and expenditure lines and budget
framework. This PforR will finance non salary operation costs (other charges - OC) including contracts with
selected HRH staff with a focus on MCH services, medicines, medical supplies, commodities,
infrastructure development for selected facilities to ensure functionality of the PHC facilities. In addition,
project will cover operation costs and capital expenditures for referral and emergency services focusing
on the MCH services at the RRH hospitals. Though the project is focusing on the PHC services, some
expenditures will be incurred at the central level (MOH and PORALG) to finance part of the operational
costs to facilitate lower-level entities in provision of essential PHC services.
33. The total cost of the government program is estimated at US$2,347 billion over the next five
years, of which US$205 million (9 percent of the total Program cost) will be financed under the proposed
PforR operation. Funding for the PforR operation includes: (i) US$180 million in IDA credit and (ii) US$30
million in Global Financing Facility (GFF) Essential Health Services grant. The HBF development partners
are expected to contribute US$163 million (or 7 percent) through parallel financing. The balance will
largely be financed from the government, although a portion will be financed through other sources. The
sources and schedule of government program financing are summarized in Tables 4 and 5, and the details
included in Table 6a and 6b in Annex 1.
Table 4. Financing Sources of the Government Program 2023-2027
Source Amount Percent of Total
(US$ millions)
Government budget 1,862 79%
International Development Association (IDA) credit 180 8%
GFF Essential Health Services grant 25 1%
Health Basket Fund 163 7%
Other sources 118 5%
Total Program Financing 2,347 100%
Table 5. Schedule of Program Financing 2023-2027
Government of IDA/GFF/Other Total
Tanzania Grants
FY 2023 423,573,562 64,528,763 488,102,324
FY 2024 409,717,671 77,528,763 487,246,434
FY 2025 400,870,728 73,528,763 474,399,491
FY 2026 396,979,764 59,528,763 456,508,527
FY 2027 394,090,743 52,528,763 446,619,505
Total 2,025,232,467 327,643,814 2,347,876,281
24 It
excludes high-risk activities, defined as those that: (i) are judged to be likely to have significant adverse impacts that are sensitive,
diverse, or unprecedented on the environment and/or affected the population; and/or (ii) involve procurement of goods, works, and
services under high-value contracts.
12
D. Description and Assessment of Program Results Framework and Monitoring and Evaluation
34. The Health Management Information Systems (HMIS) is the primary information system for the
health sector in Tanzania. The HMIS is operational countrywide and integrated into the District Health
Information System (DHIS2), a web-based software package. It comprises facility-based health records
and is used for routine health services management, providing data on morbidity, mortality, health
infrastructure, and service coverage. In addition, Tanzania has made progress rolling out the use
electronic medical records in the health facilities, though all dispensaries are yet to be covered. The
systems are robust and continue to undergo necessary upgrades.
35. The Program’s monitoring and evaluation framework (M&E) will rely on the government’s routine
HMIS with most of the data for the indicators generated through the DHIS2. Some indicators will be
monitored through other government management and administrative information databases and
information systems established under the Program. Using the government’s systems will ensure the
Program’s M&E arrangements are aligned with the government’s overall M&E framework as outlined in
the HSSP V and consistent with the M&E platforms created for the sector wide approach (SWAp) including
the HBF.
36. The DLIs selected under the Program address the major bottlenecks affecting the delivery of
essential PHC services in Tanzania. The DLIs comprise a combination of actions and outputs and were
chosen taking account of the mandates of the implementing entities and reflect priority actions from all
levels of the health system (national, regional and district) that need to be incentivized to promote
delivery of PHC services. As part of monitoring progress towards achieving the PDO, the Bank team will
conduct regular implementation support missions based on the detailed Implementation Support Plan
(Annex 9), whose focus would be on timely implementation of the agreed Program Action Plan (Annex 8),
provision of necessary technical support, conducting fiduciary reviews, and monitoring adherence to
verification protocols, where appropriate.
37. The respective M&E Units in the MoH and PORALG will have the primary responsibility for
coordinating M&E activities under the Program. The respective units will recruit/assign a dedicated M&E
officer to handle the day-to-day activities of the Program. The CHMTs are responsible for providing M&E
support to the PHC facilities, while the Regional Health Management Teams (RHMTs) supervise the
CHMTs and are responsible for data quality audits. The Program will support some of the main activities
including strengthening M&E capacity at the PHC level and scaling up use of electronic medical records
by the health facilities.
E. Program Economic Evaluation
38. Improved maternal and child health is associated with increased economic growth and reduced
poverty. One maternal death is reported to reduce GDP by US$0.42 per capita per year (in 2015 prices)25
in Africa, while poor child health contributes to stunting, poor cognitive development, and poor
performance at school.26,27 In neighboring Uganda, implementing highly effective maternal and newborn
health interventions is associated with US$10,311 per death averted and US$177 per life-year gained. The
25 Kirigia et al. (2006). Effects if maternal mortality on gross domestic product in WHO African region. African Journal of Health
Services (13): 86-95.
26 Shonkoff et al. (2012). An integrated scientific framework for child survival and early childhood development. Pediatrics, 129(2),
pp.e460-e472.
27 Victoria, C et al. (2008). Maternal and child undernutrition: consequences for adult health and human capital. The Lancet (371):
340-357
13
cost per life-year gained as a percentage of the GDP is 25.6 percent.28 It is evident that investing in
RMNCAH-N under the proposed Program could facilitate reduction in maternal and child mortality. The
Program seeks to increase the quantity and quality of PHC giving priority to emergency obstetric and
newborn care where there is a huge need. It also seeks to improve quality of antenatal, newborn, and
postnatal care services. Improved services will enable pregnant women, mothers, newborns and other
children below the age of five to live a quality life and to avert death.
Cost-benefit analysis of selected RMNCAH-N interventions
39. A cost-benefit analysis was conducted to ascertain if the expected benefits from the planned
investment outweigh the costs. While several PHC interventions will be implemented through the
Program as outlined in Box 1, the analysis only focuses on maternal and child health outcomes, specifically
the number of deaths and Disability Adjusted Life Years (DALYs) averted. By using DALYs, both the quantity
and quality of life of women and children are incorporated. The main assumptions made when
undertaking the analysis are provided in Box 1.
Box 1: Assumptions used for the economic analysis
The direct beneficiary population under the program are children aged 0-59 months; and women in child-bearing
age (15-49) estimated at 9,804,919 and 15,037,837, respectively, countrywide. In line with the program’s
development objective, the goal is to scale-up delivery of quality essential PHC services with a focus on RMNCAH-
N. This will be achieved by improved delivery of proven cost-effective interventions on maternal and child health
services; improved management and accountability in the health system; and enhanced functionality and
performance of health facilities including management of emergencies and referrals, and availability of
medicines, vaccines, and other medical commodities; and improved availability and capacity of health workers.
It is assumed that the program will expedite the reduction of deaths among under-5 children by 5 percent and 4
percent on average annually, which is higher than the annual average rates of 4.1 percent and 2.9 percent which
were observed over the periods 1990-2020 and 2000-2017, respectively. Apart from averting deaths, DALYs will
also be averted.
It is assumed that women aged 15-49 will benefit from the program through income gains from lives saved and
increased productivity due to wage losses averted and reduced or averted expenditures on medical expenses.
The children aged 0-59 months will benefit from the program through reduced or averted expenditures on
medical expenses. The number of lives saved are expressed in DALYs to incorporate the quality of life, and each
DALY averted was assumed to be equivalent to the GDP per capita of US$1,076.50 in 2020 in Tanzania. Each DALY
averted for women was equivalent to US$1,076.50 while for children it was assumed to be equivalent US$359
(one third of the GDP per capita of US$1,076.50 in 2020). However, full income gains for children are assumed to
start accruing after the age of 15. The five-year program implementation period (2022-2027) is extended by 15
years to 2038 given that investments in human development produce long term economic benefit. Further, both
the costs and benefits are discounted at a three percent discount rate in line with guidelines from the World
Health Organization (Edejer et al. 2003). WHO guide to cost-effectiveness analysis.
40. As a result of the program, about 5,736 maternal deaths and 527,414 DALYs will be averted over
the period 2022-2038. The program is also expected to avert 53,625 deaths and 5,178,553 DALYs among
children over the same period. These gains are equivalent to reductions in maternal deaths from 524 to
170 per 100,000 live births between 2022 and 2038, and Under-5 deaths from 49 to 16 per 1,000 live
births over the same period (Figure 4). Expressing the results from the cost-benefit analysis in monetary
terms also shows that the proposed program will be a very good investment for the country. At the three
28
Johns et al. (2019). The costs and cost-effectiveness of a district-strengthening strategy to mitigate the 3 delays to quality
maternal health care: results from Uganda and Zambia. Global Health: Science and Practice, 7(Supplement 1), pp.S104-S122.
14
percent discount rate, the net present value of costs and benefits are US$203.9 million and US$2,273.1
million, respectively. Subsequently, the benefit to cost ratio is estimated at 11:1 which implies that that
for every US$1 invested through this program, the benefit will be US$11. Furthermore, the cost per DALY
averted is estimated at US$45 which is significantly lower than: (a) the US$518 cost-effectiveness
threshold for low-middle income countries;29 and (b) the US$1,076.50 GDP per capita for Tanzania in
2020. The summary of the Program costs and benefits are captured in Annex 1 Table 9.
Figure 4: Expected Reduction in Under-5 and Maternal Mortality
600 60
Maternal deaths per 100,000 live births
Under-5 deaths per 1000 live births
524
500 50
49
400 364 40
300 30
32
200 170 20
100 16 10
0 0
2028
2035
2022
2023
2024
2025
2026
2027
2029
2030
2031
2032
2033
2034
2036
2037
2038
Under-5 deaths per 1,000 live births Maternal deaths per 100,000 live births
Sensitivity analysis
41. Results from the sensitivity analysis (Table 7) also shows that the proposed investment will be
viable (i.e., benefit-cost ratio more than one) even at higher discount rates of five and 10 percent. It is
also worth noting that the cost-benefit analysis did not look at the full complement of gains that can be
achieved from implementing interventions at the PHC level. As such, the estimates could have been
underestimated. This is because focus was only on maternal and child health outcomes, but the program
can also impact positively on fathers, epidemics, non-communicable diseases, and other conditions which
require a viable PHC system. In addition, given the difficulty in accounting for potential benefits from
efficiency improvements, these were excluded from the analysis. Therefore, the result of this analysis
should be interpreted as an underestimation of the potential benefits from the program.
Table 7: Sensitivity Analysis
Discount rate Cost per Life Saved Cost per DALY averted Benefit-Cost Ratio
(US$) (US$)
3% (ideal scenario) 4,366 45 11
5% 4,680 49 10
29Woods, B., Revill, P., Sculpher, M. and Claxton, K., 2016. Country-level cost-effectiveness thresholds: initial estimates and the need for further
research. Value in Health, 19(8), pp.929-935.
15
10% 5,405 56 8
F. Technical Risk Rating
42. The overall design of the operation is complex; however, it is technically sound and risk of non-
implementation of Program activities is low. The risks are mitigated by mainstreaming implementation of
the operation within the government systems, leveraging successful platforms like the HBF, building on
lessons from the previous Program (P152736) and where necessary rolling out implementation of specific
interventions in a phased manner. The roles of the main implementing entities reflect their respective
mandates to ensure accountability. Although the limited capacity of Program implementers remains a
concern, the Program’s annual capacity building plans are expected to help address this issue. Any
residual risks will be mitigated using DLIs, Program’s annual capacity building as well as TA to be
financed through parallel financing from development partners. These are summarized Table 8.
Table 8. Technical Assessment: Key Risks and Mitigation Strategies
Risks Mitigation
Technical Design
Complex design - Mainstream implementation of the operation within the
government systems, leveraging successful platforms like the
HBF, building on lessons from the previous Program (P152736)
Insufficient financing for the Program - Use of the D-Fund platform to ensure Program budgetary is
monitored within the government’s budgetary framework
New initiatives (Regional referral systems, - The initiatives will build on existing successful pilots undertaken
Mentorship, and attachment) being in the country.
implemented for the first time - Rolling out implementation in a phased manner to allow for
learning during implementation.
Risk of non-implementation of certain Program activities
Cost overruns for health infrastructure - Detailed assessments will be carried out to inform planning and
related activities execution of all major Program activities including health
infrastructure ones.
Failure to ensure the health facilities are - Detailed implementation plans developed, with specific
functional timebound actions
- Necessary capacity building activities included under the
separate DLIs
Non-implementation due to delayed releases - Accountability mechanisms for each level ofimplementers
of funds - DLIs to stimulate performance at every single level: national,
regional, LGAs and PHC facilities
Non-implementation due to lack of capacity - Detailed annual capacity building plans under theProgram for all
level
- TA provided by development partners t houghparallel financing
===============================================
16
Annex 1
Table 1: Tanzania Mainland Key Health Statistics
Indicators 2005 2010 2015 2019
Infant mortality rate (deaths per 1,000 live births) 68 51 43 36
Neonatal mortality rate (deaths per 1,000 live births) 32 26 25 20
Under-5 mortality rate (deaths per 1,000 live births) 112 81 67 50
Maternal mortality ratio (deaths per 100,000 live births) 578 454 556
Life expectancy at birth (years) 56 62 66
Stunting among children under five (%) 44 42 34 32
Total fertility rate (number) 5.7 5.4 5.2 4.9
Contraceptive prevalence rate (modern method) (%) 20 27 32
Malaria prevalence among children under 5 years (%) 18 9 14.8 7.3
Children under five years using Insecticide Treated Nets (%) 16 64 54 56
Women who received at least two doses of intermittent preventive 27 35 56
treatment of malaria in the last pregnancy in the last two years (%)
Births taking place in health facilities 45 50 63 76
Children age 12-23 months fully immunized (%) 71 75 75 90
People who know their HIV status on Antiretroviral Therapy (%) 81 92
Estimated new and relapsed Tuberculosis cases detected (%, all forms) 32 39 53
Children with diarrhea who received ORS (%) 44 45 -
ANC (at least 4 visits) among pregnant women (%) 43 51
Women (aged 15-49 years) with children under five years who took iron 17.5 28.5
and folic acid during pregnancy for past birth for 90 days or more (%)
Source: Demographic and Health Surveys (2005, 2010 and 2015), HealthStats, UNICEF, UNAIDS, UN
IGME, 2019. Tanzania National Nutrition Survey (2014 and 2018).
17
Annex 1. Table 6a. Detailed Program Budget
Area (2021/2022) 2022/2023 2023/2024 2024/2025 2025/2026 2026/2027 Total Percentage
Budget Projections
Salary Recurrent (PHC)
Personal Emoluments 196,106,832 198,067,900 200,048,579 202,049,065 204,069,555 206,110,251 1,010,345,350 43%
Non-salary recurrent
Other Charges (block
grant) 10,342,397 11,717,589 12,303,468 12,918,642 13,564,574 14,242,803 64,747,076 3%
Health Basket Fund 35,434,180 55,859,928 49,400,000 49,400,000 49,400,000 49,400,000 253,459,928 11%
PHC Medicines &
Equipment 37,939,749 38,319,146 38,702,338 39,089,361 39,480,255 39,875,057 195,466,158 8%
Infrastructure 138,970,958 106,415,258 95,773,732 86,196,359 77,576,723 69,819,051 435,781,123 19%
Development Budget
Foreign 13,000,000 24,000,000 22,000,000 13,000,000 8,000,000 80 2.4%
Regional Referral
Hospitals
Other Charges 30,319,382 30,319,382 31,835,351 33,427,119 35,098,475 36,853,398 167,533,725 7%
Development 24,309,088 24,403,121 23,182,965 19,318,945 19,318,945 19,318,945 105,542,922 4%
Development Budget
Foreign 10,000,000 12,000,000 10,000,000 5,000,000 3,000,000 40,000,000 2%
TOTAL 473,422,586 488,102,324 487,246,434 474,399,491 456,508,527 446,619,505 2,352,876,281 100%
18
Annex 1. Table 6b. Detailed Program Budget
PforR Program
Implementing Expenditure Total GoT IDA GFF HBF Others
(US$ millions)
Agency Themes
Year 1 Year 2 Year 3 Year 4 Year 5
Personal
LGA 198.07 200.05 202.05 204.07 206.11 1,010.35 1,010.35
Emoluments
LGA Block Grant 11.72 12.30 12.92 13.56 14.24 64.75 64.75
Provision of
LGA quality MCH 50.27 44.46 44.46 44.46 44.46 228.11 61 20 147
services
Provision of
MOH/PORALG
quality MCH 5.59 4.94 4.94 4.94 4.94 25.35 9 16.4
& Regions
services
PHC
MOH Medicines & 38.32 38.7 39.09 39.48 39.88 195.47 166.15 29.32
Equipment
PHC
PORALG Infrastructure 106.42 95.77 86.2 77.58 69.82 435.78 370.41 65.37
Development
HCWs
MOH training & 4 12 6 2 3 27 27
mentorship
HCWs
PORALG 2 4 2 8 8
deployment
Regional
Referral
MOH 30.32 31.84 33.43 35.1 36.85 167.53 155.14 12.4
Hospital
Services
Regional
Referral
MOH Hospital 24.4 23.18 19.32 19.32 19.32 105.54 94.99 10.55
Infrastructure
Development
Referral and
MOH emergency 10 12 10 5 3 40 30 10
services
Performance
assessments
gaps and
PORALG 2 10 6 7 25 25
performance
improvement
needs
Functional
LGA 3 4 3 10 10
PHC facilities
Program
MOH 1 1.5 1 1.5 1 6 6
Coordination
Management
and
PORALG 1 0.5 1 0.5 1 4 4
accountability
for facilities
TOTAL 488.10 487.25 474.40 456.51 446.62 2,352.88 1,861.78 180.00 30.00 163.46 117.64
19
Annex 9. Table 6: Summary of Benefits and Cost of the Program
Expected impact on No. of deaths Expected benefits
DALYs averted Total Deaths Total DALYs Total benefits Program cost
mortality averted (US$)
averted averted (US$) (US$)
Year Women Children Women Children Women Children Women Children
2022 0.0% 0.0% 0 - - - - - - - - -
2023 3.0% 4.1% 330 4,182 30,345 403,857 32,666,595 144,917,199 4,512 434,202 177,583,794 21,500,000
2024 3.5% 4.5% 373 4,402 34,341 425,084 36,967,697 152,534,188 4,775 459,424 189,501,885 43,000,000
2025 4.0% 5.0% 412 4,671 37,873 451,061 40,770,089 161,855,722 5,083 488,934 202,625,810 89,000,000
2026 4.0% 5.0% 395 4,437 36,358 428,508 39,139,285 153,762,936 4,833 464,866 192,902,221 49,000,000
2027 4.0% 5.0% 380 4,215 34,904 407,083 37,573,714 146,074,789 4,595 441,986 183,648,503 27,500,000
2028 4.0% 5.0% 375 3,993 34,444 385,644 37,078,765 138,381,910 4,368 420,088 175,460,676
2029 4.0% 5.0% 370 3,771 33,984 364,205 36,583,817 130,689,032 4,141 398,189 167,272,849
2030 4.0% 5.0% 365 3,549 33,524 342,767 36,088,868 122,996,153 3,914 376,291 159,085,022
2031 4.0% 5.0% 360 3,327 33,064 321,328 35,593,920 115,303,275 3,687 354,393 150,897,195
2032 4.0% 5.0% 355 3,105 32,605 299,890 35,098,972 107,610,396 3,460 332,494 142,709,368
2033 4.0% 5.0% 350 2,883 32,145 278,451 34,604,023 99,917,518 3,233 310,596 134,521,541
2034 4.0% 5.0% 345 2,661 31,685 257,012 34,109,075 92,224,639 3,006 288,698 126,333,714
2035 4.0% 5.0% 340 2,439 31,225 235,574 33,614,126 253,595,282 2,779 266,799 287,209,408
2036 4.0% 5.0% 335 2,217 30,766 214,135 33,119,178 230,516,646 2,552 244,901 263,635,824
2037 4.0% 5.0% 330 1,995 30,306 192,697 32,624,229 207,438,010 2,325 223,003 240,062,240
2038 4.0% 5.0% 325 1,773 29,846 171,258 32,129,281 184,359,375 2,098 201,104 216,488,656
TOTAL 5,736 53,625 527,414 5,178,553 567,761,634 2,442,177,069 59,360 5,705,968 3,009,938,702 230,000,000
Net Present Value at 3% discount rate 46,727 4,492,135 2,273,111,742 203,990,898
Cost per Life Saved (US$) 4,366
Cost per DALY averted (US$) 45
Benefit-Cost Ratio 11
20