Document of The World Bank Report No: ICR00001511 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-38410 IDA-38411 IDA-46770 IDA-H0710) ON A CREDIT IN THE AMOUNT OF SDR, 27.9 MILLION,( US$ 40.0 MILLION EQUIVALENT); SDR 40 MILLION, (US$ 60 MILLION EQUIVALENT); SDR 25.2 MILLION, (US$ 40 MILLION EQUIVALENT) TO THE UNITED REPUBLIC OF TANZANIA FOR A HEALTH SECTOR DEVELOPMENT PROJECT PHASE II December 19, 2011 Human Development Health Nutrition and Population Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective October 31, 2009) Currency Unit = Tanzanian Shilling TZH 1047.50 = US$ 1 US$ 1 =1 SDR FISCAL YEAR (HSDP II 2003) July 1 – June 30 Currency Unit = Tanzanian Shilling (AF 2006) TZH 1323.00 = US$ 1 US$ 1.589900=1 SDR Currency Unit = Tanzanian Shilling (AF 2009) TZH 1323.00 = US$ 1 US$ 1.589900=1 SDR ABBREVIATIONS AND ACRONYMS AO Accounting Officer AIDS Acquired Immune Deficiency Syndrome AMMP Adult Morbidity and Mortality Project APL Adaptable Program Lending BCC Behavior Change Communications, BFC Basket Finance Committee CAE Country Assistance Evaluation CAG Office of the Controller and Auditor General CAS Country Assistance Strategy CBO Community Base Organization CCHP Comprehensive Council Health Plans CHF Community Health Fund CHMT Council Health Management Teams CHMT Council Health Management Team DA International Development Association DANIDA Danish International Development Agency DAP Director, Administration and Personnel DDH Designated District Hospital DHIRU District Health Infrastructure Rehabilitation Unit DHMT District Health Management Team DPP Directorate of Policy and Planning DPP Department of Policy and Planning EmOC Emergency Obstetric Care EPI Expanded Program on Immunization FBO Faith Based Organization GDP Gross Domestic Product GF Global Fund GOT Government of Tanzania HAART Highly Active Ant-Retroviral Treatment HBF Health Basket Funding HCWMP Health Care Waste Management Plan HIPC Highly Indebted Poor Countries HMIS Health Management Information System HRIS Human Resource Information System HSF Health Services Fund HSSP Health Sector Strategic Plan HSSP III Health Sector Strategic Plan III IBRD International Bank for Reconstruction Development ICB International Competitive Bidding IEC Information, Education and Communication IFC International Finance Corporation IFMS Integrated Financial management System ILS Integrated Logistics System IMF International Monetary Fund IMR Infant Mortality Rate ITN Insecticide Treated Nets LGA Local Government Authorities LGA Local Government Authority M&E Monitoring and Evaluation MDGs Millennium Development Goals MKUKUTA Mkakati wa Kukuza Uchumi na Kupunguza Umaskini Tanzania MOU Memorandum of Understanding MSD Medical Stores Department MTB Ministerial tender Board MTEF Medium Term Expenditure Framework NBC National Bank of Commerce NGO Non Government Organization NHIF National Health Insurance Fund NIMR National Institute of Medical Research NMB National Microfinance Bank NPEHI National Package of Essential Health Interventions OED Operations Evaluations Department PER Public Expenditure Review PIU Project Implementation Unit PLWHAs Persons Living with HIV and AIDS PMI Presidents malaria Initiative PMO-RALG Prime Minister‟s Office-Regional Administration and Local Government PMTCT Prevention o f Mother to Child Transmission POW Program of Work PRS Poverty Reduction Strategy PSAC Programmatic Structural Adjustment Credit PSD Private Sector Development QAG Quality Assurance Group RAS Regional Administrative Secretary RHMT Regional Health Management Team SSS Single Source selection STD Sexually Transmitted Disease SWAp Sector Wide Approach TAS Tanzania Assistance Strategy TASAF Tanzania Social Action Fund Project TEHIP Tanzania Essential Health Interventions TSh Tanzania Shillings UNAIDS United Nations AIDS Program UNICEF United Nations Children Fund USAID United States Agency for International Development VA Voluntary Agency VCT Voluntary Counseling and Testing WHO World Health Organization ZTC Zonal Training Center Vice President: Obiageli K. Ezekwesili Acting Country Director: Mercy Miyang Tembon Acting Sector Manager: Jean-Jacques de St. Antoine Project Team Leader: Dominic S. Haazen ICR Team Leader: Noel Chisaka TANZANIA Health Sector Development Project Phase II Data Sheet Basic Information ................................................................................................................ i Key Dates ............................................................................................................................ .i Ratings Summary ............................................................................................................... ii Sector and Theme Codes .................................................................................................... ii Bank Staff ......................................................................................................................... iii Results Framework Analysis ........................................................................................... iii Ratings of Project Performance in ISRs ........................................................................... ix Restructuring ........................................................................................................................x Disbursement Graph ...........................................................................................................x 1. Project Context, Development Objectives and Design ...........................................1 2. Key Factors Affecting Implementation and Outcome .............................................8 3. Assessment of Outcomes ......................................................................................15 4. Assessment of Risk to Development Outcomes ...................................................27 5. Assessment of Bank and Borrower Performance .................................................27 6. Lessons Learned ....................................................................................................29 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners........31 Annex 1. Project Costs and Financing .............................................................................32 Annex 2. Outputs by Component .....................................................................................33 Annex 3. Economic and Financial Analysis ....................................................................45 Annex 4. Bank Lending and Implementation Support/Supervision Processes ................53 Annex 5. Beneficiary Survey Result ................................................................................54 Annex 6. Stakeholder Workshop Report and Results ......................................................54 Annex 7. Summary of Borrower‟s ICR and/or Comments on Draft ICR .......................55 Annex 8. Comments of Co-Financiers and Other Partners/Stakeholders ........................65 Annex 9. List of Supporting Documents .........................................................................66 MAP ................................................................................................................................72 Tables and Figures List of Tables: 1. Table 1: Funding Allocation for the HSDP 2003-2007(FY04 - FY07) 2. Tables 2a: Projected 2nd HSSP II Budget (AF 2008-2009 and AF to Support HSSP Completion and Malaria Programme. 3. Table 2b: HSSP III Financing Plan (US$): AF 2009-2010 in support of HSSP III Implementation. 4. Table2c: Disbursement of IDA funds by Credit. 5. Table 3: Breakdown of LG Audits by year for both Basket and non Pooled Funds. 6. Table 4: Performance Triggers and Status at Close 7. Table 5: Project risks and Status at Close 8. Table 6: Breakdown of Project Outcome Ratings 9. Table 7: Progress on Malaria Treatment 10. Table 8: Progress in HIV Interventions 11. Table 9: Legal Covenants and Status at Close 12. Table 10: Tanzania, Demographic and Health Indicators (2004-5 and 2010) 13. Table 11: Causes of Death for Infants (2006) 14. Table 12.1: Neonatal Death Model (2005) 15. Table 12.2: Neonatal deaths averted (2006-2011) 16. Table 12.3: Results of the economic analysis for averted infant death (2005- 2010) 17. Table 13: Net Present Value and Internal Rate of Return (2005-2019) 18. Table 14: Trends of Nominal and Real Per Capita allocated to Health, 2006/07 – 2010/11 List of Figures: 1. Figure 1: Tanzania Mortality Rates in comparison with rest of SSA 2. Figure 2: Tanzania top ten cause of Mortality in patients over five admitted in Hospitals. 3. Figure 3: Comparison of Key Service delivery Outcomes in Tanzania and the rest of Sub Sahara Africa Region 4. Figure 4: Financing of the Health Sector 5. Figure 5: Trend Analysis of Procurement over time: 2004-2008 6. Figure 6: Initiatives to Improve Quality of health Services in Tanzania. 7. Figure7: Human resources Establishment and Percent Deficit 8. Figure 8: Distribution of Human Resources for Health across different Health Care Levels 9. Figure 9: Proportion of Health Workers by Region 10. Figure 10: Spending on Health as a percent of total Government Expenditure 11. Figure 11: Health Sector Spending as a Percent of total Government Expenditure. 12. Figure 12: Comparison OOP 2005/2006 with other countries in SSA 13. Figure 13: Progress Coverage and Utilization of LLINs/ITNs 14. Figure 14: Progress on RH Interventions 15. Figure 15: Percentage of Deliveries in Health Facilities 16. Figure 16: Progress in Nutrition Interventions (TDHS 2009/10) 17. Figure 17: Progress DPT-HB3 Immunization 18. Figure 18: TB Treatment Success Rate by Region 19. Figure 19: Distribution of Pharmaceutical Products in Tanzania 20. Figure 20: Availability of Medicines by type of Facility 21. Figure 21: Selected Stock out rates for Common Pharmaceutical Products 22. Figure 22: Total Health Spending by Source of Funds (2005-2006) A. Basic Information Second Health Sector Country: Tanzania Project Name: Development Project IDA-38410, IDA- Project ID: P082335 L/C/TF Number(s): 38411, IDA-46770, IDA-H0710 ICR Date: 12/28/2011 ICR Type: Core ICR UNITED REPUBLIC Lending Instrument: APL Borrower: OF TANZANIA Original Total XDR 45.30M Disbursed Amount: XDR 110.45M Commitment: Revised Amount: XDR 110.45M Environmental Category: B Implementing Agencies: Ministry of Health and Social Welfare Ministry of Regional Administration and Local Government Co financiers and Other External Partners: German Federal Ministry for Economic Cooperation (BMZ/GTZ) UNFPA UNICEF World Health Organization (WHO) United Nations Swiss Agency for Development and Cooperation UK-funded DFID Canada - CIDA Embassy of Denmark Embassy of Netherlands Embassy of Norway Africa Development Bank B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Effectiveness: 03/18/2004 03/18/2004 Review: Appraisal: 11/03/2003 Restructuring(s): 12/31/2010 Mid-term Approval: 12/16/2003 03/13/2006 03/21/2006 Review: Closing: 12/31/2007 06/30/2011 i C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Low or Negligible Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Implementing Satisfactory Satisfactory Supervision: Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Quality at Entry Project at any time No Satisfactory (QEA): (Yes/No): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 10 10 Health 80 80 Non-compulsory health finance 10 10 Theme Code (as % of total Bank financing) Child health 29 29 Decentralization 14 14 Health system performance 29 29 ii Malaria 14 14 Nutrition and food security 14 14 E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Mercy Miyang Tembon Judy M. O'Connor Act Sector Manager: Gayle Martin Dzingai B. Mutumbuka Project Team Leader: Dominic S. Haazen Julie McLaughlin ICR Team Leader: Noel Chisaka ICR Primary Author: Noel Chisaka F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the phase II project is to achieve improvements in the provision of quality health services through continuing to support the reforms, capacity development and improved management of resources, while placing a greater emphasis on quality. Revised Project Development Objectives (as approved by original approving authority) The PDO was not revised during the lifetime of the project. (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Indicator 1 : Infant Mortality Rate (per 1000 live births) Value quantitative or 99 85 54 51 Qualitative) Date achieved 12/31/1999 06/30/2004 12/31/2007 06/30/2010 Comments The target were revised twice, down to 85 in the first AF and then further (incl. % down to 54 for the end target. The target by end project was successfully achievement) achieved. Ratio of the IMR of the poorest quintile to the IMR of the least poor Indicator 2 : quintile Value quantitative or 1.29 1.22 1.08 1.12 Qualitative) iii Date achieved 01/01/1999 12/31/2007 12/31/2010 10/30/2009 Comments The original target was exceeded but the revised target was not attained. (incl. % However, there was significant progress towards attaining the revised achievement) target Indicator 3 : Under Five Mortality rate ( per 1000) Value quantitative or 146.5 130 86 81 Qualitative) Date achieved 01/01/2003 12/31/2007 12/31/2010 10/04/2010 Comments The targets were revised downwards. Both the original and revised targets (incl. % were exceeded achievement) Indicator 4 : Total fertility rate 15-49 Value quantitative or 5.6 4.5 5.4 5.4 Qualitative) Date achieved 01/01/1999 12/31/2007 10/04/2010 12/31/2010 Comments The original target of 4.5 was considered unattainable given the (incl. % Governments lack of attention to this issue. The revised target was achievement) achieved. Indicator 5 : Life expectancy at birth Value quantitative or 49 updated to 51.70 50 52.70 55.77 Qualitative) Date achieved 12/22/2002 12/30/2007 12/31/2010 12/31/2008 Comments (incl. % Original and revised targets attained and exceeded. achievement) Indicator 6 : Maternal Mortality Ratio (per 100 000) Value 370 revised to 578 quantitative or 250 391 454 based on DHS data Qualitative) Date achieved 12/31/2004 12/30/2007 12/31/2004 09/30/2010 Comments The attained ration represents a reduction of 21% indicating significant (incl. % progress towards attainment of target. achievement) iv (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Achieved at Values (from Revised Indicator Baseline Value Completion or Target approval Target Years documents) Values Indicator 1 : Government Health Budget per capita Value (quantitative 6.6 9.0 14 13.98 or Qualitative) Date achieved 12/31/2004 12/31/2007 12/31/2009 12/31/2010 Comments Increased from 11$ as target for first Additional Financing (12/31/2009). Target (incl. % achieved. achievement) Indicator 2 : Proportion of births attended by skilled health worker Value (quantitative 47 55 57 51 or Qualitative) Date achieved 01/01/1999 12/31/2007 12/31/2010 10/31/2010 Comments Substantial Progress towards attainment of target. Inadequate emergency obstetric (incl. % units and staff shortages contributed greatly to non attainment of this target. achievement) The percentage of clients seeking health care at a health facility report to be Indicator 3 : satisfied. Value (quantitative Unknown 65 68 62 or Qualitative) Date achieved 07/01/2003 12/31/2009 12/31/2010 10/31/2009 Comments Previous target of 65% for 12/31/2009 likely to be exceed. Indicator updates only (incl. % due in 2012 Household Budget Survey. achievement) Indicator 4 : The TB treatment completion rate (cure rate) Value (quantitative 80 85 90 87.5 or Qualitative) Date achieved 01/01/2003 12/31/2007 12/31/2009 12/31/2010 Comments Original and first additional Financing target of 85 exceeded. Progress towards (incl. % attainment of revised target substantial. achievement) Indicator 5 : The proportion of malnutrition( weight for age among children under five Value (quantitative 29 25 18 20.7 or Qualitative) Date achieved 07/01/2003 12/30/2007 10/01/2010 12/31/2010 v Comments Substantial progress towards achieving target. DHS 2009/2010. Target for first AF (incl. % was 20.0 achievement) Health workers trained pre service to minimum qualifications and certification Indicator 6 : ( total number of students enrolled) Value (quantitative 899 5000 8599 6450 or Qualitative) Date achieved 08/01/2004 12/31/2003 12/31/2010 12/31/2010 Comments Target from the HSSP III. No change from the 2008 enrollment values. Target (incl. % partially achieved (75%) achievement) Indicator 7 : The proportion Immunization DPT3/Penta under - Target is MDG 2015 Value (quantitative 81 80 90.0 85.7 or Qualitative) Date achieved 12/31/2009 12/31/2004 12/31/2010 12/31/2010 Comments The 90.0% target is the HSSP III target for 2015 year ending. Progress toward (incl. % attainment of targets very good. Target partialy met. achievement) Indicator 8 : Patients treated for TB (number of cases for the fiscal year ending date shown) Value (quantitative 64298 60000 66000 63364 or Qualitative) Date achieved 06/30/2004 12/31/2004 12/30/2009 12/31/2010 Comments (incl. % Target not achieved achievement) The proportion of Vitamin A supplementation for children under 6-59 months -DHS Indicator 9 : data Value (quantitative 12.5 30 50.0 60.8 or Qualitative) Date achieved 12/31/1999 12/31/2004 12/31/2010 10/31/2010 Comments (incl. % HSSP II target is set at 80%. From DHS .2009/10, Target achieved and exceeded achievement) Indicator 10 : Modern contraceptive prevalence 15-49. ( % of married women only) Value (quantitative 16.9 20 25 27 or Qualitative) Date achieved 12/31/1999 12/31/2004 12/31/2010 10/31/2010 Comments DHS 2009/10 shows target achieved and exceeded. (incl. % vi achievement) Indicator 11 : Use of insecticide nets by vulnerable groups Value 25% (CU5) 72.6(CU5) (quantitative 40 26% (PW) 67.6 (PW) or Qualitative) Date achieved 02/01/2008 12/31/2010 10/31/2010 Comments (incl. % Target substantially exceeded. achievement) Indicator 12 : Availability of emergency obstetric care Value (quantitative 5 10 20 5 or Qualitative) Date achieved 12/31/2005 12/31/2005 12/31/2010 12/31/2010 Comments Process of procurement of emergency obstetric equipment finalized. A time of ICR, (incl. % no assessment on new levels of availability. However following procurement, levels achievement) in facilities increased. To be validated by 2012 DHS. Long Lasting Insecticide treated nets purchased and or distributed. (Core Indicator 13 : Indiccator) Value (quantitative 0 2400000 2400000 2400000 or Qualitative) Date achieved 07/02/2007 07/02/2007 12/30/2009 12/01/2009 Comments (incl. % Target met achievement) Indicator 14 : Direct project beneficiaries (Core Indicator- Number) Value (quantitative UNKNOWN 7800000 7800000 7990000 or Qualitative) Date achieved 12/31/2004 12/07/2008 12/31/2010 12/31/2010 Comments (incl. % Target achieved. IDA represents 19% of total basket funding achievement) Indicator 15 : Female beneficiaries. (proportion) Value (quantitative 50.8 50.80 or Qualitative) Date achieved 12/31/2009 12/31/2010 Comments (incl. % achievement) Indicator 16 : Health Personnel receiving training (number) Value UNKNOWN 2500 3600 13000 vii (quantitative or Qualitative) Date achieved 12/31/2004 12/31/2007 12/31/2010 08/01/2010 Comments (incl. % Target exceeded. IDA contributes 19% of total basket funding achievement) Indicator 17 : Children immunized (number) Value (quantitative UNKNOWN 1350000 1350000 1545536 or Qualitative) Date achieved 12/31/2004 12/31/2010 12/31/2010 12/31/2009 Comments (incl. % Target exceeded. IDA contributes 19% of total basket funding achievement) Indicator 18 : Children receiving a dose of Vit A (number) Value (quantitative UNKNOWN 6500000 6,500,000 6 626 367 or Qualitative) Date achieved 12/31/2004 12/31/2010 12/31/2010 12/31/2009 Comments (incl. % Target exceeded. Total number, proportion attributable to IDA funds not available. achievement) Indicator 19 : Percentage of health facilities with designated malaria drugs in stock Value (quantitative 25 or Qualitative) Date achieved 12/31/2003 Comments (incl. % Indicator dropped achievement) Indicator 20 : Annual procurement audits find that there improvements each year Value (quantitative N/A Report Done Report Done or Qualitative) Date achieved 12/31/2004 12/31/2008 12/31/2010 Comments (incl. % There was progressing improvements in the audit reports over time achievement) The annual health sector review assess the status of the Implementation of the Indicator 21 : Health Care Waste Management Plan (number of reports) Value (quantitative N/A Report Done Report Done Report Done or Qualitative) Date achieved 12/31/2004 12/31/2009 12/31/2010 12/31/2010 viii Comments (incl. % Reports on this issue not seen. achievement) Gradual shift from of Bank financing from APL to PRSC compensated for by Indicator 22 : increases in govt allocation of govt allocation to HC 15 M/yr under APL II Value 15 M/yr under APL II 30M/yr under 5 M/yr under APL II and 25 and 15 M/yr (quantitative and 0M/year under APL II and 0M M/year under PRSC ( 0M under PRSC or Qualitative) PRSC/ under PRSC under PRSC) (0M under PRSC) Date achieved 12/31/2004 12/31/2008 12/31/2007 12/31/2010 Comments This indicator was not achieved as the APL did not move to PRSC due to non (incl. % attainment of conditions by client achievement) Indicator 23 : Percentage of children with cough of fever who are take to a health facility Value (quantitative 67.5 80 30.1 or Qualitative) Date achieved 12/31/1999 12/31/2007 10/31/2010 Comments (incl. % Target not archived. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 02/17/2004 Satisfactory Satisfactory 0.00 2 10/21/2004 Satisfactory Satisfactory 18.93 3 05/09/2005 Satisfactory Satisfactory 29.03 4 12/06/2005 Satisfactory Satisfactory 44.16 5 06/27/2006 Satisfactory Satisfactory 49.91 6 12/21/2006 Moderately Satisfactory Moderately Satisfactory 59.20 7 03/22/2007 Satisfactory Satisfactory 59.20 8 11/01/2007 Satisfactory Satisfactory 70.16 9 05/23/2008 Moderately Satisfactory Moderately Satisfactory 85.78 10 08/29/2008 Moderately Satisfactory Moderately Satisfactory 86.04 11 12/24/2008 Satisfactory Moderately Satisfactory 101.21 12 06/15/2009 Satisfactory Satisfactory 102.79 13 12/07/2009 Satisfactory Satisfactory 120.54 14 06/14/2010 Satisfactory Satisfactory 143.29 15 12/28/2010 Satisfactory Satisfactory 160.38 ix 16 06/28/2011 Satisfactory Satisfactory 162.02 H. Restructuring (if any) ISR Ratings Amount Board at Disbursed at Restructuring Reason for Restructuring & Key Approved Restructurin Restructurin Date(s) Changes Made PDO Change g g in USD DO IP millions To facilitate the procurement of 12/31/2010 N S S 160.42 emergency obstetric equipment and allow the I. Disbursement Profile x 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Economic and Sector Context. In 2003, with a GDP per capita of US $260, Tanzania remained one of the poorest countries in the world. Although the country had experienced average real GDP growth of around 5% per year since the introduction of the Poverty Reduction Strategy in 2000, thirty-five percent of the population still lived below the national poverty line, and the country ranked 160th in the United Nations‟ Human Development Index. Achieving the Millennium Development Goals (MDGs) remained a major challenge for Tanzania, given that the health-related MDG indicators had been stagnant or had worsened during the 1990s. Infant mortality rates (IMR) and child mortality rates (CMR) had worsened from IMR of 92 per 1,000 live births in 1992 to 99 per 1000 live births in 1999 and CMR from 141 per 1000 in 1992 to 147 per 1000 in 1999. The prevalence of HIV/AIDS was 12% (2002), and life expectancy at birth had dropped from 52 years in 1990 to 49 years in 2003. Total fertility rate remained high at 5.6. At the time, more than 70% of life years lost in Tanzania were due to preventable causes, notably malaria, diarrhea, pneumonia, HIV/AIDS, perinatal and maternal conditions. Figure 1 compares Tanzania mortality rates with the rest of SSA, whereas Figure 2 takes a closer look at Tanzania‟s top ten causes of mortality in patients over five years old. Figure 1: Tanzania Mortality rates in comparison with rest of SSA Figure 2: Tanzania top ten cause of mortality in patients over five admitted in hospitals Source: MoHSW 2008 1 Figure 3: Comparison of key service delivery outcomes in Tanzania and the rest of Sub Sahara Africa region Figure 3 takes a more comprehensive view of service delivery outcomes in comparison to the rest of SSA as of 2010; Tanzania is well ahead in most of the delivery outcomes. 2 2. Health Sector Reforms and the SWAp. In 1999, the Government of Tanzania (GOT) embarked on a health sector reform program to focus on implementing the essential and most cost-effective health interventions given the burden of disease and to transform financing, management and delivery roles by emphasizing quality, empowerment of local authorities and the beneficiary, and greater use of non-government agents. Tanzania's Poverty Reduction Strategy (PRS) of October 2000 focused on reducing income poverty through sustaining macroeconomic stability, rural sector development, export growth, and private sector development. In line with the sector reform program and PRS, a three-phase, long-term (2000- 2011) Health Sector Development Program (HSDP II) was jointly developed by the GOT and Development Partners (DP). The HSDP II Project supported the Second Health Sector Strategic Plan (HSSP II)1. Grounded in the Poverty Reduction Strategy (PRS), the HSSP II was appraised and endorsed by all partners in April, 2003. The HSSP describes roles and responsibilities for all levels of the health system. This program was supported through a Sector-Wide Approach (SWAp)2. The various modes of financing of the health SWAp include government budget (excluding budget support) 51%, general budget support from partners 20%, pooled funding 14% and direct project funding 15%. In these cases, project funds are employed to finance specific designated activities under the MTEF or District Plans, with GOT and pooled funds filling in the balance of the costs. Malaria and AIDS receive substantial earmarked funds and these sub-programs are mainly project financed. Figure 4 shows the different modes of financial support for the SWAp. The funding supports the implementation of the MOHSW Medium Term Expenditure Framework (MTEF) and the 133 Comprehensive Council Health Plans (CCHP). Figure 4: Financing of the Health Sector Figure 1 - Health Sector Financing 2000/01 to 2010/11 in $ millions, total $4.2 billion Other DPs, $541 , 12.8% Health Basket, GOT, $3,557 , $666 , 15.8% 84.2% World Bank, $125 , 3.0% Source: MoHSW 2008 3. Rationale for Bank involvement. The Bank assisted the country in translating government-led investment in health, nutrition and population into achievements of its 1 HSSP II: The Strategic Plan has objectives and targets organized under three components: district health services, secondary and tertiary hospitals, and central support. The emphasis o f the 2003-2008 strategic plan was s on “district health services� Component 1, where most of the essential health services are provided. HSSP II looked at significantly improving the quality of those essential health services, make Council Health Management Teams and district health providers more accountable and strengthen community ownership. Component 2 focused on “the secondary and tertiary hospitals� as a way of ensuring good quality of health services delivered at these levels. Component 3 “Central support� was to ensure effective planning and implementation of health services through an effective regional level and a well focused central ministry. 2 Under the 1999-2002 Program of Work (POW), commendable achievements were made regarding joint planning and evaluation of planned activities, as well as pooled/basket funds arrangements under the SWAp. The British, Dutch, Danish, Irish, Swiss and German governments pooled all or parts of their financing to (a) finance central MOH procurements and activities that appear within the Medium-Term Expenditure Framework, and (b) provide grants to districts in support o f non-personnel recurrent costs in district plans and budgets. 3 development objectives. The Bank worked closely with the other development partners who coordinated their contributions (financial, technical and other) through a Sector-wide Approach (SWAp) in support of the government defined sector development program. This program was reflected in the Second Health Sector Strategic Plan (HSSP II) and the accompanying Medium- Term Expenditure Frameworks (MTEFs). The rationale for the Bank involvement in the SWAp was to mobilize the Bank's comparative advantage vis-a-vis the other partners3. The Health Basket pooled funds from eleven development partners in order to reduce transaction costs and strengthen government systems. 1.2 Original Project Development Objectives (PDO) and Key Indicators 4. The objective of the phase II project was to achieve improvements in the provision of quality health services through continuing to support the reforms, capacity development and management of resources, while placing a greater emphasis on quality. The following key indicators were designed to monitoring the progress of the project. The indicators would also be used for assessing the long-term impact of the Health Sector Development Project. a) Infant Mortality Rate (IMR) (99.1 in 1999). b) Ratio of the IMR of the poorest quintile to the IMR of the least poor quintile (113:88 in Under-five mortality rates (146.5 in 1999). c) Life expectancy at birth (49 in 2003). d) Total fertility rate 15-49 (5.6 in 1999). e) Maternal Mortality Ratio (370/100,000 women of child bearing age per surveillance in 2002). 5. As the APL was supposed to shift through to PRSC at the third phase, the following milestones were to be used to monitor suitability to transition. a) The gradual shift of Bank financing for health from the Adaptable Program Loan to the PRSC is compensated for by increases in the allocation to the health sector. b) Annual procurement audits find that there are improvements each year. c) The Annual Health Sector Reviews assess the status of implementation of the Health Care Waste Management Plan. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 6. The PDO was never revised during the lifetime of the Project. However, a number of indicators and target values were revised to reflect the implementation progress and other additional financing over time. Major indicators revised or dropped include (description of magnitude of revision and effect is found in the data sheet). a) Infant mortality Rate. 3 The Bank was to play the following role during the implementation of the SWAP through the HSSP II. “(a) complementing government financing and the financing of other partners; (b) liaising with central ministries: Finance, Planning Commission, President Office:) to foster synergy between health sector initiatives and the range of development initiatives outside the health sector; (c) transfer knowledge and providing policy advice related to health sector financing, human resources for health, and the role of the private sector; and (d) encourage and enable the MOH to pay greater attention to monitoring the impact of reforms. 4 b) Ratio of the IMR of the poorest quintile to least poor quintile. c) Under five mortality rate. d) Total fertility rate. e) Life expectancy. 7. Intermediate outcome indicators revised were: a) Government Health Budget per capita; value increased from 9 to 14 US$ per capita in the first AF. b) Percentage of health facilities with designated anti-malaria drugs; - dropped. c) Total fertility rate was revised upwards. 1.4 Main Beneficiaries 8. The main beneficiaries of the HSDP II were Tanzania households, especially women, children and other vulnerable persons as the project focused on improving the provision of health care to the overall Tanzanian population, as stipulated in the PDO. The project was designed to cover 100 percent of the districts hospitals and health centers, making improved services available for up to 100 percent of the population. As the main component of the project was improving district health including quality, all district hospitals and primary health facilities within districts in local government areas were beneficiaries to the project. In ear marked project funds, such as the food fortification initiative, it benefited up to 23 million people, and the malaria bednet programme directly benefited 7 990 000 people, of which 50.8% were female. Other project beneficiaries included people living with HIV/AIDS. 1.5 Original Components 9. The second Phase of the Health Sector Development Program (HSDP II) built on the success of HSDP I. It continued to address constraints of effective implementation of the health interventions - namely, sector financing, human resources, logistics, management and information systems, quality assurance, decentralization and the role of the private sector. The HSDP II was developed to support the implementation of the HSSP II, taking into account that the HSSP II was developed in line with Poverty Reduction Strategy (PRS) agreed to by all partners; the HSDP II program components are the same as HSSP II components. The estimated cost at the time of project design was US$963 million, of which IDA was to finance US$65 million. Of this, US$ 40 million was IDA and US$ 25 million was from a grant. The project had two Additional Financings from 2007-2009 for IDA US$60 million and the second AF for 2009-2010 for IDA US$ 40 million. The total HSDP IDA financing was US$165 million (original US$65 million and US$l00 million AF), with US$125 million or 76% going to the Health Basket. As for Phase I Project, Phase II was implemented by the Ministry of Health (MOHSW) and the District Councils under the President's Office, the Regional Administration and Local Authority (PMO-RALG). Table 1 provides a summary of funding allocations for HSDP II (2003-2007), while Tables 2a and 4b highlight the contribution of the two AF. 5 Table 1: Funding Allocation for the HSDP 2003-2007(FY04 - FY07) Ministry of Health GOT Portion IDA Portion Total USD (Million) US (Million) USD (Million) Total (Central Government) 389.09 28.50 417.59 PMORALG Total (Region/LGA) 573.53 36.50 610.03 Cumulative Total 962.62 65.00 1027.62 Table 2a: Projected 2nd HSSP II Budget (AF 2008-2009 and AF to support HSSP Completion and Malaria Programme) Ministry of Health GOT Portion IDA Portion Total USD (Million) US (Million) USD (Million) Total (Central Government) 702.10 29.27 731.37 PMORALG Total (Region/LGA) 421.18 30.73 451.91 Cumulative Total 1123.28 60.00 1183.28 Table 2b: HSSP III Financing Plan (US$): AF 2009-2010 in support of HHSP III Implementation COMPONENTS FY09/10 FY10/11 Total AVAILABLE RESOURCES (including DP) 861,460,000 971,940,000 1,833,400,000 RESOURCE GAP¹ 386,437,284 390,329,699 776,766,984 Basket Funds 15,900,000 15,000,000 30,900,000 Non-pooled Funds 1,100,000 8,000,000 9,100,000 TOTAL IDA FINANCING 17,000,000 23,000,000 40,000,000 Cumulative Total (IDA and Available resources) 878,460,000 994,940,000 1,873,400,000 A large proportion of the resource gap relates to the rehabilitation, furnishing and construction of dispensaries, which are funded directly by the GOT and depend on the availability of their own resources. Source: 2009 AF PP. A brief description of the components: 10. Component One: Improving District Level Health Services DLHS (US$ 98.3 4 million): The DLHS is the focus of health implementation; hence the importance of improving coverage, access and the quality of health services delivered at this level. The activities were addressed through developing district health manager cadre, strengthening in- service training, implementing the health care waste management plan, rehabilitation and renovation of primary health care facilities, ensuring that adequate technical and support capacity available to councils at LGA level and supporting health care delivery in primary health facilities. In addition, the component would strengthen the integration of HIV/AIDS activities into service delivery at all levels, and increase accountability by publishing annual district health budgets and performance data. 4 The ratio of funding is obtained from the table of total costs in the original project between the components in Annex five of the PAD. 6 11. Component Two: Strengthening the Management of Secondary & Tertiary Hospital Care (US$ 66.7 million- Includes Component Three): Hospital management would be improved by developing a hospital manager cadre, mandating Hospital Strategic Plans and operational plans, establishing Hospital Boards, and strengthening hospital financial management. Quality would be improved through repairs to facilities and preventive maintenance, implementing the health care waste management plan, and enhanced performance audits including monitoring of service delivery outputs. 12. Component Three: Strengthening the Central Level Stewardship Role: The central and regional levels would be responsible for standard setting, quality control, financing and human resource development for the sector. At regional level, capacity would be improved through provision of managerial and technical support to districts, supporting districts in decision-making, strengthening district capacity for supportive supervision, and facilitating inter-district exchange of experiences. At central level, Central Ministries Health financing would be increased and made more efficient and sustainable through improved budgeting, increasing the government allocation for health and pooling of external finances. The Human Resource crisis would be addressed through long-term manpower planning, more strategic use of Zonal Training Centers (ZTCs), and innovations to address distribution, motivation and retention of staff. 1.6 Revised Components 13. No components were revised. The HSDP II contributed to the health sector reform programme through implementing the HSSP II focusing on district health care delivery, secondary and tertiary level care and the strengthening of the Ministry of Health capacity in advocating for increased health financing and increasing both the number and quality of human resources in the delivery of health care. 1.7 Other significant changes 14. The program did not change in terms of scope, design, implementation arrangements and schedule during the implementation time frame. However, the scale was somewhat increased to include more focus on programmatic areas for malaria through the procurement of ITNs and re-treatment kits through the first Additional Financing (AF) and support to the Food Fortification Program and procurement of emergency obstetric equipment through the second AF. The project had three extensions. The first, from December 31, 2007 to December 31, 2009, was to support the implementation of the HSSP II and the implementation of the malaria programme activities. The second, from December 31, 2009 to December 31, 2010, was to support (a) the implementation of the food fortification programme through the National Food Fortification Alliance, (b) the purchase of emergency obstetric equipment which would help increase the proportion of pregnant women delivering in health facilities, and (c) the successful ending of HSSP II and initiate the implementation of the HSSP III. The third extension, from January 1, 2011 to June 30, 2011 was to facilitate the completion of the procurement of this emergency obstetric equipment. The scope of implementation of the HSDP and the two AF was guided by the HSSP II which did not change during the life of the project, as this was the long term health development strategy of the country (2003-2007). The introduction of new activities for malaria and food fortification was a result of MoHSW‟s request for specific funds 7 to meet new and emerging demands that could not be adequately addressed through the original financing arrangements. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 15. The Quality at Entry for HSDP II (2005) was rated “Satisfactory� overall by the Bank‟s Quality Assurance Group (QAG), and the Strategic Relevance and Approach was rated “Highly Satisfactory�. The HSDP II was a continuation of the long term HSDP from 2000-2011. The project preparation benefited from the Phase I of the APL and was developed intensively with representatives of the Government, NGOs, and other donors in order to ensure that the program adapted to and was consistent with the needs of those who were responsible for implementing it, especially the MOH line directors and PMO-RALG, and that it would meet the expectation of the beneficiaries. The project was designed to support overall health reform within the context of the SWAp, being implemented under the councils at district level through the process of decentralization by devolution. This design had great strengths in taking health as close to the people as possible but at the same time suffered on issues of increased complexity in implementing arrangements, such as lack of capacity in the periphery and complex administrative procedure. The lessons reflected in the development of the HSDP II were: a. Recognition by Governments and donors of the need for government ownership of programmes and the implementation of a more comprehensive approach on a government-led sector strategy and program that focused on building government systems and capacity (rather than capacity to manage only donor financing) and an agreed comprehensive financing framework. b. Recognition for focusing on the core functions of government and strengthening its role in the health sector by shifting away from service delivery to focus on stewardship and financing. c. Recognition for the need to coordinate human resource strategies with civil service reforms. d. Recognition for the need for improving the Health Management Information System (HMIS) and building demand for information at all levels as a requirement for good sector management. e. Recognition for the importance of strengthening reforms in hospital management. 16. Lending instruments: IDA‟s support over the period 2000-2011 was to be in three phases. Phase I from 2000-2003, phase II from 2003-2007 and Phase III through a PRSC from 2008 -2011. The first phase of the Health Sector Development Program was a US$22 million Adaptable Program Lending (HSDP I, Credit 33800) implemented from 2000 to 2003. HSDP II was a US$65 million second phase APL (Credit 38410, Grant H0710) approved in 2003, with an original Closing Date of December 2007, which supported the implementation of HSSP II. At negotiations of HSDP II, the GOT expressed its preference to have a larger share of development assistance disbursed through General Budget Support (GBS). It was therefore, agreed that IDA‟s financial support to the sector would be folded into the Poverty Reduction Support Credit (PRSC) by 2008 rather than continue through the third phase of theAPL, subject 8 to meeting the three conditions5. As GOT did not fully meet the PRSC entry conditions6, the two Additional Financings were part of the third phase given that the project did not progress to PRSC as was originally envisaged. This phased IDA was designed to support the implementation of the health reforms and explains the apparent extensions in the project closing dates. As districts still relied heavily on the pooled funds to finance operating costs of health facilities, and there was not yet a public finance mechanism which could fully substitute for these funds. A reduction in the pooled fund upon the closing of the HSDP II (including its additional financing) would have created a shortfall in financing at the service delivery level. 2.2 Implementation 17. The project had some minor restructuring, outside of the two additional (AF) financings. A request was made to extend the closing date to June 30, 2011 to allow for the procurement of emergency obstetric equipment and also to ensure that the implementation of HSSP III was on course. This restructured extension also allowed for support from the Governments of Australia and Switzerland through co-financing trust funds, AUD 2 million from Australia and US$2 million from Switzerland this increased the amount of equipment to be purchased by about 50% which would further increase the effectiveness of the intervention. The mid-term review was conducted and the findings were responsible for realignment of the project implementation. 18. Project disbursements: By June 30, 2011, the project had fully disbursed, including resources from two trust funds from the Swiss Development Cooperation and the Australian government. The disbursement delays from the Bank and Partners were very minimal. The table below highlights the disbursements as described by Government Table 2c: Disbursement of IDA funds by Credit Utilization of Project funds provided by IDA Credit/Grant Original Actual Disbursements (US $) % of Number Financing Disbursement Amount (US $) Disbursements Non Pooled fund Total to Basket Fund Disbursements Disbursements Credit 38410 - TA 40,000,000.00 34,419,677.01 6,974,933.71 41,394,610.72 103.49 Credit 38411 - TA 60,000,000.00 35,000,000.00 27,056,189.26 62,056,189.26 103.43 Credit 46770 - TA 40,000,000.00 30,900,000.00 7,795,488.00 38,695,488.00 96.74 Sub - Total 140,000,000.00 100,319,677.01 41,826,610.97 142,146,287.98 Grant H071 - TA 25,000,000.00 25,876,793.89 - 25,876,793.89 103.51 Sub - Total 25,000,000.00 25,876,793.89 - 25,876,793.89 Total 165,000,000.00 126,196,470.90 41,826,610.97 168,023,081.87 TF99966 1,609,640.00 - - - - TF99967 1,864,976.25 - 1,628,411.00 1,628,411.00 87.32 Sub - Total 3,474,616.25 - 1,628,411.00 1,628,411.00 Total 168,474,616.25 126,196,470.90 43,455,021.97 169,651,492.87 Source: Govt ICR 2011: Note: The amount of actual disbursement in excess of the original financing amount is the utilization of foreign exchange gains caused by exchange rate fluctuations between the SDR and US $. 5 . i) increased Government allocations to the health sector to accommodate the shift of IDA financing for health from the APL instrument to the PRSC; ii) improved procurement performance by the Borrower in each fiscal year of project implementation as assessed by procurement audits; and iii) annual reviews of the implementation of the Health Care Waste Management Plan (HCWMP). 6 The proportion of the government budget being devoted to health has declined over recent years; the proportion (excluding Consolidated Fund Services) has decreased by 4.1 1 percentage points, or 29.1%, The 2009/10 health sector budget increased by 9.0%, which given 10.9% inflation and 3.1 % population growth amounted to a real per capita reduction. 9 19. Legal Covenants: At project inception legal covenants were defined that would guide the implementation of the Project. The choice of the covenants was deliberate to ensure that HSDP II effectively contributed towards coordination between DP and governments and also ensured that there was enough capacity within the implementing agencies to deal with fiduciary and procurement issues. The choice of the covenants was realistic and no exceptions were sought during the lifetime of the project over any one covenant. The covenants included annual audit, conduct of joint annual reviews between partners and Government and the provision of critical disbursement precedent that no disbursement would be made until a Memorandum of Understanding (M-O-U) had been entered into among the Borrower, the Association and the other Donors contributing to the Pooled Funds7. The MOU was duly signed and remained in effect during the entire period of the project; although it was updated in September 2008. Each of the additional legal covenants was implemented and by closure of the project all the legal covenants had been complied with. (See Annex 9: Table 9: Legal Covenants and status at close). 20. Adequacy of Government involvement and commitment: Even though the GOT did not meet the condition required to have shifted the APL to PRSC8, the Government continued to commit fully to the implementation of the HSDP II, within the context of the Memorandum of understanding signed with the DPs. The LGA at council level devoted time to ensure that the planning of health was given priority within the development agenda. The development of CCHP guided implementation at council level and PMO RALG and MoHSW worked jointly in improving coordination arrangements at LGA level. In addition, the level of HR for health targeted by GOT was high in order to meet the demands of implementing HSSP effectively. 21. Risks and their Mitigation: The identified risks at project design were substantive given the HSDP II was deriving lessons from the HDSP I. These risks were substantially addressed during the implementation of the Project. The impact of HIV/AIDS in the sector was partially mitigated under the National Multi-sectoral Strategic Framework for HIV/AIDS to which the Bank‟s Tanzania Multi-Sectoral Aids Project (TMAP) contributed, and received substantial support from other donors, closer adherence to the „health planning‟ process was laid down in the Procedure Manuals for the joint Disbursement System for the District Basket Fund and the Central Basket Fund and this was implemented as per signed MOU between DP and GOT. (See Annex 9: Table 4: Risk mitigation status at close) 22. Performance Triggers: The choice of performance triggers were appropriate as they addressed the overall GOT health delivery system and focused on the areas of most concern that would be challenging during the implementation of the HSDP II. The triggers were improved upon during implementation of the HSDP II. For example, Government and donor commitment 7 . Other Legal covenants were: 1. the government will organize a joint annual review in March-April of each year to review the progress o f implementation as well as a plan and budget for the subsequent year. 2. The government will submit to IDA and other development partners at least 4 weeks before each annual joint review: (a) an annual report on implementation progress, expenditures, and results o f any technical reviews; and (b) a plan of action for subsequent year. 3. On a quarterly basis, the government will (a) submit to IDA and other development partners‟ reports on implementation progress and expenditures, and (b) organize basket financing committee meetings. 4. Annual financial audit reports, carried out by an independent, will be submitted to IDA and other development partners within six months after each financial year. 5. Annual external procurement audit reports will be submitted to IDA and other participating partners after each financial year. In addition to the formal annual audits, ad-hoc procurement reviews may be conducted periodically. 8 . The conditions that government did not meet are: i) increased allocation, ii) improved procurement performance and ii) the HCWMP discussion at annual reviews 10 was sustained, challenges by partners and GOT on disbursement to the health basket had largely been resolved, and additional donors had been added to the basket, with the result that in FY08/09 some 11 development partners (DP) provided over US$81 million in funding, up from 9 DPs and US$68 million in FY07/08. By 2010, the health basket had approached $90 million representing 15% of the total health sector budget and 17% as IDA support. The health basket had become the funding modality of choice among development partners. As of July 2003, all districts produced comprehensive plans and received grants against district plans and this continued till closure of the project. The national guidelines for an Essential Health Package were developed and costed; during the project implementation review of the same was done. Training guidelines across different disciplines were developed and used in the MPH program and selected functioning zonal training centers. District level training is ongoing. A review and revision of the planning guides was done to take into account the review of the basket restrictions for use of funds, and for inclusion of a minimum set of preventive nutrition interventions. For the Quality Assurance program, access to drugs and training was strengthened. (See Annex 9: Table 5: Performance triggers status at close). 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization: Linking Implementation to results Framework 23. The monitoring and evaluation of the project is described in two parts: 1) Monitoring of the administrative and coordinating arrangements to ensure that the SWAp was being effectively managed; and 2) Monitoring and tracking of the results framework indicators on the delivery of project outcomes. 24. The Director of Health Policy and Planning (DHPP) of the Ministry of Health (MOH) were responsible for day-today coordination and monitoring of the project while closely cooperating with the MOH‟s Chief Medical Officer (CMO) and PMO-RALG‟s Director of Local Government through the Health Sector Reform Secretariat. The MOH and PMO-RALG‟s responsibility was to coordinate sector-wide planning and performance evaluations 9 . A participatory Monitoring and Evaluation (PME) was adopted during the project M&E design. This was seen as the most appropriate project design as it required the active involvement of the key stakeholders in the implementation of the project. The Results Framework and the monitoring arrangements were consistent with those from HSDP II and indicators supporting the monitoring of the HSSP II. 25. The MoH prioritized the strengthening of routine monitoring of health outcomes and performance through HMIS as well as through specific surveys for broader sector wide progress monitoring. To this end, the HSDP II involved two Demographic Health Surveys, one Malaria/HIV indicator survey, a number of program reviews including a midterm review, joint sector program reviews and annual programme reviews. Key performance indicators were 9 The following was used to continuously monitor different aspects of the project. 1).Joint Annual Review including a review of the training program (part of the Project‟s Annual Work plan), was carried out in March of every year preceded by a technical review to assess actual expenditures and achievements over the year against the plans and review, the MTEF for the coming fiscal year, financial audit for the previous year and the procurement audit of December 31 of previous year. 2). Quarterly Basket Finance Committee meetings that involved Senior Management from MOH and PORALG as well as donor representatives channeling funds through the Basket; 3). Annual Sectoral Public Expenditure Review (PER) and a Health Sector Performance Profile; 4). Quarterly progress reports were submitted by the districts with nineteen indicators established to monitor progress in the implementation of the District Health Plans; 5). Financial Management and Audit Reports (FMR): Financial Management reports were submitted quarterly and reviewed by the Task team. 11 agreed upon by MOH and Development Partners, and incorporated into the PRSP. As the project underwent two AF, targets which were exceeded (e.g., IMR and under-5 mortality) were revised upwards. The total fertility rate target was seen as not likely to be met, and was adjusted upward. The AF also introduced IDA Core Indicators to the results framework; these were a) Children immunized (number); b) Health personnel receiving training (number); c) Children receiving a dose of vitamin A (number); and d) Long-lasting insecticide-treated malaria nets procured and/or distributed (number). As a result, the monitoring framework for HSSP III resulted in several changes in indicators, including the ones for malaria (see results data sheet for details). Data showing progress of the SWAp towards meeting the MDG/MKUKUTA goals and the implementation of the overall health sector is readily available. Significant progress was also made in the development of regular reporting mechanisms and the mainstreaming of the process for annual expenditure reviews and sector performance profile reports. (See more results in Annex 2: Outputs by component) 2.4 Safeguard and Fiduciary Compliance 26. Fiduciary: The responsible persons for the project in the MOH were the officers of the Health Strategy Unit. Two accountants were designated whose roles were to handle Bank related documentation for funds out and inside the basket (Central and District). These financial management arrangements were deemed adequate in meeting the Bank‟s minimum requirements for financial management for the project. 27. The Tanzania Country Financial Accountability Assessment (CFAA) was carried out and completed in the year 2001. The assessment concluded that while Tanzania had a “sound system of formal rules for financial management and many of these rules had been recently updated and strengthened, issues of non compliance, limited execution, inadequate monitoring, insufficient capacity, and lack of enforcement needed to be resolved�. These were the focus of strengthening during the implementation of the project as reflected in the risk mitigation measures (see Annex Table 9b: risks and mitigation) The Local Government Reform Programme (LGRP) Progress report for the period of July to December 2002 showed steps were undertaken to strengthen the Local Government financial management systems10. The project provided funding for both basket and non basket activities. The Non basket fund activities were for central government utilization and programme support for both malaria and nutrition, including support for procurement of drugs through the Medical Stores Department (MSD). The central funds eventually trickled down to the districts through central level funded activities such as capacity building, facility rehabilitation and drug revolving funds from the MSD to Hospitals and Districts. 28. Unaudited Interim Financial Reports (IFRs) were produced by the MOHSW quarterly and these helped in monitoring the progress of the project. The project complied with all legal covenants, including the requirement that procurement audits be submitted annually. The project assessment of OP 13.20, “implementation of the project, including substantial compliance with loan covenants, was deemed satisfactory�. Audits of the Special Account 10 . These include: (a) the assessment o f the financial management capacity in all districts Local Government Authorities (LGAs); (b) the use o f new guidelines for preparation o f development plans and budgets; and (c) use of new chart of accounts under the Government Financial Statistics (GFS) codes by all LGAs. 12 (Category 2 non-pooled expenditures) and SOE reviews were satisfactory. Unqualified audits from the Controller and Auditor General (CAG) were by end of the project being received on time. Audits of the pooled fund (Category 1) were the responsibility of the CAG but were conducted by a contracted external auditing firm up to and including the 2006/07 audit. The 2006/07 and 2007/08 Audits were submitted late. The audits were reviewed in regular meetings of the joint GOT-DP Audit Subcommittee which noted improvements over time. The Basket Fund audits were mostly qualified11. An action plan to address the qualified audit issues raised was developed in consultation with the Bank and other DPs. The DPs were very proactive in engaging with the government so that plans of action (POA) acceptable to the DPs are developed and implemented to deal with both the various audit recommendations and general financial management issues, and these were monitored on an ongoing basis. The financial management assessment took into consideration the overall fiduciary risk associated with use of country systems and basket funded operations. It confirmed that appropriate mechanisms were put in place over the years of implementation that meet the requirements under OP/BP 10.02. 29. Procurement: Procurement for the Second Health Sector Development Project (HSDP II) and both AF were carried out in accordance with the World Bank‟s “Guidelines: Procurement under IBRD Loans and IDA Credits� dated May 2004; revised October 1, 2006; and “Guidelines: Selection and Employment of Consultants by World Bank Borrowers� dated May 2004; revised October 1, 2006, and the provisions stipulated in the Legal Agreement. The project management unit had a total of twenty procurement staff of which six procurement staff was mainly involved in procurement of the ongoing Phase II program. The PMU was responsible for undertaking procurement activities for the HSDP I1 financed by both the Government and DPs. The overall project risk for procurement was noted as high and corrective measures and mitigation actions were taken12. Figure 5 illustrates the analysis of the overall procurement performance which shows improvement especially for procurement process activities such as preparation of bid documents, bidding, evaluation and general compliance with PPRA. However, shortcomings remained prevalent in contract management, supervision of projects and delayed payments. 11 . The main reasons for the FY07/08 qualified audit were: (i) the amount of the expenditure reported by MoHSW in the income and expenditure statement was overstated by TZS. 2,692,14 1,262 (approximately US$ 2 million); (ii)0 .3% of the expenditures for which payment vouchers could not be located; and (iii)a salary payment to one employee who was on unpaid leave (about US$ 4,400 or 0.03 percent of the Basket Fund expenditures) was not refunded by the responsible staff. The first issue related to the year-end transfer of funds from one government account to another (i.e., Basket Fund account) for annual reconciliation, which was processed but not yet effected. The second issue relates to filing problems which are currently being addressed and the employee in the third issue has now returned to work at MOHSW and there is every expectation that a full refund will occur. 12 . These are; training staff in data management and procurement filing; providing the procurement staff with adequate working space, and facilities for safe keeping of documents; and selecting contracts below the new threshold to undergo prior review. 13 Figure 5: Trend analysis of procurement over time: 2004-2008 Table 3: Breakdown of LG Audits by year for both basket and non pooled funds . Financial Health Basket Local Government Authorities (LGAs) Non pooled funds Year (MOHSW) provided by IDA 2003/2004 Qualified audit 52 LGAs out of 113 LGAs received Qualified Unqualified audit opinion audit opinion, 61 LGAs received a disclaimer. opinion 2004/2005 Qualified audit 80 LGAs out of 113 LGAs received Qualified Unqualified audit opinion audit opinion, 33 LGAs received a disclaimer. opinion 2005/2006 Qualified audit 1 LGA received Unqualified audit opinion, 84 Unqualified audit opinion LGAs out of 113 LGAs received Qualified audit opinion opinion, and 28 LGAs received a disclaimer. 2006/2007 Qualified audit 2 LGAs out of 121 LGAs received Unqualified Unqualified audit opinion audit opinion, 97 received Qualified audit opinion opinion, and 22 LGAs received a disclaimer. 2007/2008 Qualified audit 72 LGAs out of 133 received Unqualified audit Unqualified audit opinion opinion and 61 Qualified audit opinion. opinion 2008/2009 Unqualified audit Out of 131 LGAs and 5 RASs; 44 received Unqualified audit opinion Unqualified audit opinion, 49 Qualified audit opinion opinion, 8 adverse and 35 disclaimers. 2009/2010 Unqualified audit 18 LGAs out of 132 received Unqualified audit Unqualified audit opinion opinion, 44 received Unqualified audit opinion opinion with emphasis of matter, 55 Qualified audit opinion, and 3 adverse and 12 disclaimers. Source: Govt ICR 2011. 30. Environment: The HSDP Phase II was categorized as a “B� under the Environmental Assessment. The project supported the delivery of health services and would therefore only generate medical waste. The project built on what the MAP had started in financing; the revision of existing health sector guidelines on appropriate management of hazardous medical waste at medical facilities and at disposal sites to include the relevant dispositions regarding HIV/AIDS, and other Medical Waste. A Health Care Waste Management Plan (HCWMP), including a set of National Guidelines was developed. The HCWMP focused on the reduction of hospital waste and on developing sanitary landfills, as opposed to incineration. The training of national staff in these guidelines was key in monitoring the implementation of the HCWMP. 14 Implementation of the Health Care Waste Management Plan began in FY06/07, and the first planned implementation review was held during the May 13, 2009 Bi-annual SWAp Meeting. It was noted that progress had been made but that more needed to be done especially on the training performed and on reporting of activity implementation. An update of the HCWMP was completed in 2007. Subsequent to this routine implementation of the HCWMP was done. This has been reflected in the development of the new project to ensure that extra emphasis is placed on scaling up the actions of the revised 2007 HCWMP. 2.5 Post-completion Operation/Next Phase 31. A number of important developments occurred between 2003-2007 where the Bank started looking at a shift in its approach towards supporting decentralized levels, i.e., local governments and communities. The Bank‟s letter to the GOT of February 24, 2009 suggested consolidating some of the existing funding mechanisms to the decentralized level into a few multi-sector local government baskets, thereby reducing transaction costs and further promoting alignment to country systems. The focus of this approach would be to concentrate primarily on the protection and promotion of basic social services at the local level, providing a framework for multi-sector support to local service delivery. As part of the 2nd AF, the request to extend by one year was in part to ensure that the new HSSP III implementation was initiated while paying significant attention to building governance and accountability structures at the local level. This was to ensure that efforts to build capacity and improve local service delivery (such as the supply chain from the district to the health facility level) would be sustained over time13. This is currently on going through the revision of the Comprehensive Community Health Plan (CCHP) guidelines that reflect the focus of HSSP III and enhance accountability at the community level. A new project along this approach is currently under preparation. This project will help build on the gains attained in the HSDP II and will continue to focus on local service delivery ensuring long term sustainability through capacity building. 3. Assessment of Outcomes 3.1 Effectiveness and Relevance of Objectives, Design and Implementation 32. Relevance of the PDO: Relevance of the PDO is rated SUBSTANTIAL. The PDO contributes not only to the CAS but also to higher level country objectives relating to Tanzania's Poverty Reduction Strategy (PRS) of October 2000 14 . The PRSP committed to reducing morbidity, improving nutrition and strengthening access to health services “in order to raise the productive life of Tanzanians�. The Health Sector Development Program (2000-2011) is the government‟s long-term strategy to implement the PRS in the health sector. 33. Relevance of design and implementation: Relevance to design and implementation is rated SUBSTANTIAL. The adoption of the SWAp broadened the interactions between the MOH, MOF and PMO-RALG (President‟s Office, Regional Administration and Local 13 . This is responding to the need for effective system at district level as the basis for the effective implementation of a more decentralized basket. 14 This focused on reducing income poverty through sustaining macroeconomic stability, rural sector development and export growth, and private sector development., improving human capabilities, survival and well-being through improving education, health, social well-being, reducing vulnerability and protecting the environment. 15 Government) and the donor community. The Tanzania Assistance Strategy (TAS)15 and the February, 2003 Rome Declaration on Harmonization recommended that donors adopt joint actions, harmonized rules and procedures. The project design and implementation matched the DP work through country systems to strengthen and improve the delivery and quality of health care services working through the SWAp. 34. Relevance of the PDO to the CAS: The relevance of the PDO to the CAS is rated SUBSTANTIAL. The Bank‟s Country Assistance Strategy (CAS) FY00-FY03 for Tanzania supported the PRS and built on the Government‟s Tanzania Assistance Strategy (TAS). The Program and Project were consistent with the aims of the CAS and PRS. The CAS highlighted both service delivery and better coordination of development assistance, endorsing sector wide approaches and the move to program (rather than project) support. The CAS stated that the Bank would retain significant focus on health16. Both the first and second AF were developed within the context of the 2007-2010 CAS, that stated: “An ongoing investment program in health will be extended through FY 10 with supplemental financing that address short term financing gaps. Thereafter it is expected that IDA‟s health financing will be provided through PRSCs.� The second Financing continued to support IDA‟s 2007-2010 CAS focusing on harmonized aid modalities through participation in the health SWAp, reflecting on the need for more share of GBS and recognizing the greater efficiency and impact achieved through sector- wide approaches. 3.2 Achievement of Project Development Objectives 35. The PDO of HSDP II was substantially achieved and rated Satisfactory 36. The project development objective was to improve the provision of quality health services through continuous support of reforms, capacity development and improved management of resources, while placing a greater emphasis on quality. In order to do this, the following intermediate goals were recognized: 1. Effective central and regional level support to quality, financing and human resources. 2. Improved District Level Health Services. 3. Strengthened Management of Secondary and Tertiary Hospital Care. 37. The HSDP II (2000-2011) was developed as a sector project that formed the backbone of implementing the HSSP II (2002-2008). The development of the HSDP II was a follow-up from the HSDP I whose objective was to improve resource management and the quality of health services through sector reforms and institutional capacity building. Drawing on the lessons and achievements of the HSDP I, the HSDP II was developed to support the implementation of HSSP II and ensure that the health reforms initiated during the HSDP I were implemented successfully and sustained. The main object of the HSDP II project was to 15 . The TAS makes specific reference to aid modalities, encourages capturing external assistance on-budget, and promotes the use o f pooled funds. 16 The Health Sector Development Program contributed to three of the four CAS pillars. private sector development, improved social infrastructure to enhance access or the poor to essential public services, and public sector reform and institution building, to increase the effectiveness o f public service delivery and improve governance . 16 improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women, and children. The project had three main components which focused on service delivery standards reflecting global recommendations such as attainment of the MDGs. The three components were designed to support a defined package of cost-effective interventions which were expected to improve delivery of quality health services. The HSDP II continued to address effective implementation of these interventions - namely, sector financing, human resources, logistics, management and information systems, quality assurance, decentralization and the strengthened role of the private sector. This section discusses the implementation of the main focus areas with the major implementation areas being discussed in the Annex 2: Output by Component Section. 38. Decentralization: The GOT‟s focus on health care reform began in 1994 with the goal to improve access, quality, and efficiency of service delivery. The main focus of reform was to strengthen primary health care, district health services, secondary and tertiary service delivery. An important part of this was the policy of Decentralization by Devolution (D by D), which transfers authority and responsibility for health care from the central MOHSW to Local Government Authorities (LGAs). This policy was enacted through the 1998 landmark legislation, Policy Paper on Local Government Reform, based on the principle of political devolution and decentralization of functions and finances within the framework of a unitary state. 39. Health services in Tanzania are now delivered through a decentralized system whereby local governments (under the Prime Minister‟s Office–Regional Administration and Local Government, or PMO-RALG) are responsible for service delivery through dispensaries, health centers, and district hospitals. The implementation of the decentralization policy is still the subject of major efforts under the Local Government Reform Program II to iron out lingering challenges in the separation of roles and responsibilities between PMO-RALG and other ministries, including the MOHSW. Efforts are also under way through various government initiatives (some with development partner support) to strengthen LGAs‟ ability to deliver services by improving their management capacity and programmatic and financial accountability and to streamline working relationships between ministries. Under the decentralized structure, the MOHSW is responsible for: a. Policy formulation, regulation, control, quality assurance; and monitoring and auditing. b. Resource mobilization and allocation, coordination, and inter-sect oral linkages. c. Management support to level-three hospitals, including national, referral, and special hospitals. d. Public health-related interventions. e. Health and social welfare research. f. Management of executive agencies. g. Supervision of preventive and curative health services delivery. h. Training key professional health cadres and monitoring the quality of training offered by private institutions (COWI 2007). 17 40. However, to effectively carry out its responsibilities, the MOHSW collaborates closely with PMO- RALG and the LGAs, which fund and oversee all district-based health activities. The MOHSW relies on LGAs to implement new policies, allocate resources, deliver health services, and provide health data. In addition to working with LGAs, the MOHSW must also collaborate with several other ministries: the Ministry of Finance and Economic Affairs (MOFEA) to provide funding, and the Ministry of Higher Education, Science and Technology (MHEST) to train health workers. The delineation of responsibilities between the MOHSW and LGAs increases the complexities for the MOHSW in overseeing effective service delivery and consistent policy implementation. The GOT is undertaking the Local Government Reform Program (2008-2013), aimed at eliminating bottlenecks and improving coordination with line ministries. The devolution of responsibilities for health facilities and health planning to Local Government Authorities has contributed to improved health sector delivery in Tanzania – the associated financial support (through the Health Basket Fund and Block Grants) has been essential to achieving this result. Councils and their health management teams are able to undertake meaningful budgeting through the CCHP (Comprehensive Community Health Plans) and to supervise and operate local health facilities. 41. Quality of Care (QoC): QoC is one of the HSDP II outcomes for improved service delivery. To achieve this, the GoT working with Development Partners embarked upon the development of policies, strategies, guidelines, action plans, and manuals that focus on general and disease-specific quality improvement. With increased focus for QoC in the HSSP III, Standard Operating Procedures, Treatment Guidelines, and overall standards are being developed to support implementation of quality health services. A Quality Improvement Framework Programme has been developed corresponding to an accreditation system for public and private service providers to enhance quality of health service delivery in Tanzania. Figure 6 highlights QoC initiatives being developed across different levels of health care delivery. Figure 6: Initiatives improve quality of health services in Tanzania 42. Human Resources for Health: The health sector continues to face a serious human resource challenge. This HR crisis is negatively affecting the ability of the sector to deliver quality health services. There is a severe shortage of HR at all levels. The current establishment of health service workers was noted to be half the total number required to effectively implement health service delivery. The shortage is more severe in rural districts and at lower level health facilities. Clearly, even though the number of health workers has increased with 18 support of the HSDP, HRH still remain a big challenge for the MOHSW. Figure 9 below provide a good illustration. The shortage is exacerbated by the HIV/AIDS pandemic, malaria, TB, and population increase. Low output of qualified staff, mal distribution, poor remuneration, poor infrastructure, lack of attractive retention schemes and migration to other countries after training, and inter-sectoral movement also contribute greatly to the crisis. To mitigate this crisis, and as part of government commitment to HRH response, government put in place initiatives aimed at addressing this issue. The measures put in place include; long-term manpower planning; innovative distribution to the districts especially rural areas; motivation and retention of staff (including defining explicitly the role of Local Government Authorities (LGAs) in relation to human resources for health); and the more strategic use of Zonal Training Centers (ZTCs) and the use of incentives for rural facilities. The government also embarked on a massive training program that saw more than 6000 new health workers trained. Figure 7 highlights the HR for health availability by cadre of health worker and percentage deficit. Figure7: Human resources establishment and percent deficit 43. Regarding availability of health staff, Figure 8 provides information on the deficit of staff across different levels of health care in 2006 in the public sector. The total gap reflected across levels is 65%. This is much higher than the gap by type of health cadre available. The difference could be attributed to the private sector taking some of the health personnel thereby further aggravating the already critical shortage in public facilities. However, in rural areas there was a noted increase in private to government health worker migration following the increase of salaries in 2007/08. The MOHSW programme of continuous worker recruitment and training is aimed at increasing the human resource base. However, the magnitude of need is great and compounded by other external factors of attrition, this is a big problem for the Ministry. Progress made in improving both numbers and quality of cadres trained at all levels is evident. 19 Figure 8: Distribution of Human resources for health across different health care levels 44. Another challenge is that health worker distribution across regions is not uniform. Rural regions are less served as compared to urban regions. The figure 9 shows the distribution of heath cadres by regions. Figure 9: Proportion of Health Workers by region 45. The management of HIV/AIDS, MCH, IMCI, EPI and treatment of malaria was covered at all levels of the health system with health centers being the focus of health care delivery. This is discussed further in the annex; output by component section. At this point it will suffice to say that improvement of the indicators was achieved. In addition, it was noted the HSDP was the primary support for hospital rehabilitation and repair. Figure 7 provides an overview of the number of medical staff available and the deficit. Clearly with a deficit of 39.4% across all cadre types, it‟s quite challenging to deliver quality health services. (See Annex 2: Output by Component Section) 46. Health Sector Financing: Tanzania has a mixed system for health financing. 70% from public and foreign financing and complemented by health insurance in the form of National Health Insurance Fund (NHIF), and Community Health Fund (CHF) and user fees in the form of cost sharing. From the 2003/04 to 2008/09 financial years, the share of the health sector in total government budget and expenditures had remained well below the 15% target of 20 Abuja Declaration. However, actual health expenditure may have increased from 10% of total government spending including Consolidated Fund Services (CFS)17 in 2004/05 to about 12% in 2005/06. Despite a modest increase to 11% of actual spending in 2007/08, the share of the health sector budget in the total government budget (including CFS) dropped slightly to 10% in 2008/09 due to the fact that total government budget increased slightly faster (20%) than the increase in budget allocations to the health sector. Total public health sector spending in nominal terms in the 2010/11 budget estimates are almost four times the level in 2004/05. The largest increase has been in foreign non-basket funding and a substantial part of this is due to the Global Fund grants now being shown “on-budget�. Spending per capita has increased by a factor of 2.5 from $7.51 to $18.56 (estimates); although actual expenditure is often lower than the estimated amount. Excluding debt service and related items, the percent of the total government budget spent on health per capita increased from 11.3 percent in 2004/05 to 14.1 percent in 2005/06 and then declined steadily to 12.1 percent in 2008/09. There was some improvement in 2009/10 increasing to 12.9 % with a further estimated decrease in 2010/11 to 12.1 Figure 10 illustrates the spending on health over time and the percentage spent on health. Figure 10 below also shows a corresponding increase government spending in Tanzanian shillings from TZS 206 554 Shillings in 2004/2005 to TZS 643011 million shillings in 2010/119 (approved estimates). Figure 10: Spending on Health as a percent of total Government expenditure Source of Funds 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 (TZS million) Actual Actual Actual Actual Approved Actual Approved Actual Approved Expenditure Expenditure Expenditure Expenditure Estimates Expenditure Estimates Expenditure Estimates Government Funds 206,554 296,819 348,890 378,113 459,496 461,504 548,658 578,682 643,011 Foreign Basket 91,777 68,299 103,204 80,956 99,730 85,401 121,640 128,796 161,804 Non Basket 2,896 61,257 61,512 112,003 204,368 154,168 254,801 200,049 387,908 Total Foreign 94,673 129,555 164,716 192,959 304,098 239,569 376,441 328,845 549,712 Off-budget 3,384 3,363 2,964 15,289 0 5,858 0 10,784 0 Total 304,612 429,738 516,570 586,361 763,594 706,931 925,099 918,311 1,192,723 Real Spending (FY05=100) 304,612 403,693 460,825 478,347 566,980 524,907 640,851 636,148 791,153 Real per Capita (TZS) 8,328 10,707 11,856 11,939 13,728 12,709 15,052 14,941 18,074 Real per Capita (USD) 7.51 8.98 9.49 9.46 10.40 9.63 11.34 11.26 12.31 Total as % GoT (ex. CFS) 11.3% 14.1% 13.3% 12.2% 11.1% 12.1% 11.6% 12.9% 12.1% Total as % GoT (inc. CFS) 10.1% 11.9% 11.8% 11.0% 10.0% 10.8% 9.7% 9.8% 10.3% Percent of total Government Funds 67.8% 69.1% 67.5% 64.5% 60.2% 65.3% 59.3% 63.0% 53.9% Basket 30.1% 15.9% 20.0% 13.8% 13.1% 12.1% 13.1% 14.0% 13.6% Non Basket 1.0% 14.3% 11.9% 19.1% 26.8% 21.8% 27.5% 21.8% 32.5% Total Foreign 31.1% 30.1% 31.9% 32.9% 39.8% 33.9% 40.7% 35.8% 46.1% Source: MoFEA 2010 47. Figure 11 below shows the health sector spending as percentage of Government expenditure. It is important to note the gradual decline from 2005/06 financial year till 2009/10 financial year. This was a cause for concern for overall SWAp and contributed to not meeting the condition of moving from APL to PRSC. 17 Consolidated Fund Services (CFS) which is largely funds used to pay public debt. + 21 Figure 11: Health sector spending as a percent of total government expenditure 16% 14% 12% 10% 8% 6% 4% 2% 0% 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 Est. With CFS No CFS Source: Tanzania Health system assessment 2010 48. The financing at district level is mostly through the health basket user fees, block grants and the Health insurance reimbursement and community health funds. The health basket is seen as the most reliable source of funding at district, let alone all levels. The utilization of other funds outside the basket still remains sub optimal. Among the challenges is the need to increase capacity across the districts especially at health centre level were most of the activities are delivered. In addition, there is inadequate funding from the health basket and irregular disbursement of block grant making implementation of work plans rather challenging; the ceilings tied with the disbursements make rational management of resources difficult especially in relation to rehabilitation and refurbishment. There is also inconsistent supply of medicines from the Medical Stores Department. This cuts across all levels of health facilities. The MSD attributed this to a number of factors of which irregular and inconsistent disbursement of funds from the MOHSW was noted. In addition, slow procurement processes and cumbersome donor processes could have contributed to this erratic availability of drugs at MSD. 49. Public Private Partnerships: The 1999 Programme of Work laid out the vision that the “public private mix will be promoted in the delivery of health services. This included a specific Public/Private Mix Strategy to develop new ways of promoting private sector participation through contracting out services and adopting the required legislation. The Government was “to be more of a facilitator than the main provider of health services.� Four years after the POW was published, the HSSP II noted that “the only significant achievement reported within the area of PPP was the registration of new facilities�. Notably the factors that limited the development of PPP were limited concept and practice; mistrust between the public and private sectors; ownership of the providers rather than the health services provided and utilized was and remains a major sticking point; funding and resource sharing arrangements at the council level were not sufficiently equitable. For a way forward, there is a serious need of a policy and strategy document on PPP to guide its implementation including guidance on equitable sharing of resources at council level. 50. Health Insurance Mechanism The new financing policy included cost sharing and user fees, as well as insurance mechanisms for the health sector. Fees are collected at all health facilities, with a system of waivers which targeted different populations (civil servants, rural population, etc.), but overall insurance coverage in Tanzania remained quite low. 51. National Health Insurance Fund (NHIF): The NHIF is a statutory health insurance scheme established by the Act of Parliament no. 8 of 1999, amended to Act no. 25 of 2002. The NHIF uses a fee for service method to reimburse its service providers. However, reimbursement has remained comparatively low due to low level of claims, thus NHIF has built a considerable 22 reserve (Tanzania-German Programme to Support Health 2006). The HSDP II provided US$ 2.0 million in 2004 for this activity. 52. Community Health Funds (CHF): The CHF started in 1996 as a pilot scheme in Igunga district and was later expanded to other councils with the expectation of eventually covering the whole country (Ministry of Health 1999). The CHF was introduced as an alternative to user fees charged at public health facilities. It is designed to cover people in the informal sector and rural areas. As part of the project, the HSDP II was to finance a component of the health financing at community level of which US$ 2.0 million was provided in 2004 to support pilot phase in 10 districts. Current uptake rate remains low and does not seem to be moving as rapidly to meet its target. 53. Out Of Pocket payments: Tanzania fares poorly on the level of Out Of Pocket (OPP) contribution to utilization of health services. The high rate of OOP health financing underscores the importance of strengthening alternative health financing mechanisms to improve on risk protection especially for poor families in rural area so that OOP does not become a barrier towards health care utilization. Figure 12 shows the comparison of OOP with other countries in SSA. The 2008 NHA are showing a decreasing trend in OOP. (Data yet to be published.) Figure 12: Comparison OOP 2005/2006 with other countries in SSA 54. These different financing mechanisms offer an opportunity for increased sustainability in health financing. However, they require increased devolution and development of systems to support effective implementation of the schemes. As of now, all of the schemes are functioning below optimal levels. It is hoped that the HSSP III will provide increased focus on the processes and policies required to improve alternative health financing methods to compliment GOT budget allocations on health. 55. Logistics, Management and Information Systems: Within the Health Information and Research Section (HIRS) of the Policy and Planning Division of the MOHSW the HMIS Unit processes and analyses routine data from all health facilities. The section also conducts surveys together with the National Bureau of Statistics and has a National Sentinel Surveillance Unit (integrated into the MOH in 2002 after the completion of the Adult Morbidity and Mortality Project). On the basis of information collected through these various systems the section prepares all information required for the JAHSR, the MKUKUTA, GBS and the MDGs and is responsible for compilation of the Annual Health Statistics report. It was noted that the HMIS data continues to be intermittent and unreliable despite considerable external support with 23 utilization and analysis at district level still minimal 18. Despite this, the overall partnership observes that HMIS significantly improved with improved collection and management of data at facility level. The data obtained for the project though remains relevant and valid due to the number of surveys done through the MoH system with support from external partners that have complemented the information for the MoHSW to make decisions. Given the observed challenges, the HSSP III has placed greater emphasis on strengthening his area further. 56. Progress towards Results Framework indicators: As of October, 2009, HSDP II had already exceeded targets for two out of four project development objective indicators. By December 2011, the DHS results clearly showed that the project indicators for five of the PDO had been exceeded. Indeed, addition progress to the remaining PDO was substantial. (See data sheet). Reductions in the infant mortality rate (IMR) and the under-five mortality rates (USMR) were among the greatest observed in Sub-Saharan Africa over the last several years. Progress has also been made in the equity indicator of the IMR distribution, with the 2007/08 figures showing that 80% of the gap between the baseline and the target had been covered achieving the target set at project development. By Dec 2010, Infant mortality rate had dropped further to 51/1000 live births. Less than five mortality rate was also dropped from 144/100 in 2008 to 81/1000 in 2010 a 44% reduction. In addition, after years of stagnation maternal mortality ratio declined from 578/100 000 live births in 2004 to 454/100 000 live births in 2010. The implementation of a systematic HSSP II which the HSDP II supported appears to have had an impact in improving the different service delivery outcomes, especially the infant mortality and child mortality as attested by a number of independent peer reviewed articles and the independent evaluation report. The summary finding of the SWAP evaluation concluded that the SWAp had contributed to improvements in health outcomes and to the quality of health services at community level. These improvements can, in turn, be plausibly linked to progress toward MDG and PRSP/MKUKUTA goals, especially relating to infant and child mortality. (See Annex 2: Output by Component Section) 57. Project ISR ratings: ISR ratings for implementation progress and development objectives were consistently satisfactory during the project life, with one exception when implementation and development objectives were rated marginally satisfactory due to the turn-over of MOHSW management and associated interruption in pace of implementation. The ISR at the time stated that it anticipated that the downgrading would be temporary and that the next ISR would be upgraded, which it was. Delays in implementation were attended by GOT as per recommendation of the DP (see ICR data sheet). 3.3 Efficiency 58. Contributions to efficiency: The project contributed to harmonizing government and donor mechanisms so that the DP efforts become complementary to the country implementation 18 . Technical Review of Health Service Delivery at District Level, Final Report, by HERA, March 2003 24 of the health sector. The development of the different SWAp committees and the DP participation in the SWAp was instrumental in the consolidation of the system and management of donor funded support. This was a critical efficiency gain for the MoHSW as it reduced the operating costs for managing different donor funded activities. In addition, the annual review and planning sessions optimized the planning cycle and eliminated duplication on planning. The issue of financial and procurements management was part of the broader agreement through the memorandum of understanding between the DP and the MoHSW and allowed the DP to provide a joint intervention plan that helped build MoHSW capacity and contributed to strengthening both financial and procurement processes. 59. Returns to project investment - Health System Strengthening: The HSDP focus was on delivery of quality health interventions through strengthening of the health system. The project contributed to increased integration of activities at service delivery level and increased the human resource base for effective health service delivery. The project developed and strengthened the management capacity of health at different levels of care through training and recruitment and supportive supervision both from the central level and the zonal centers. Innovative initiatives were being put in place to promote retention. 60. Returns to project investment - Health Financing and PPP: The implementation of the HSSP III 2009- 2015 is supported by the additional financing of the HSDP for the first two years and is taking more focus on the implementation of the health financing and PPP. The MoHSW recognizes the importance of these two facets of health implementation. Even though there are some challenges in the scaling up of the health financing initiatives in the HSDP II, the HSSP III takes up from where the HSSP II left and consolidates on the gains, leveraging on the lessons leant to ensure the health sector financing is sustainable over time. Coming from a traditional culture of total government health care financing and negligible PPP, the progress attained so far lays the foundation of taking these two areas of health care provision to the next level. 3.4 Justification of Overall Outcome Rating 61. The overall Project outcome is rated Satisfactory. The implementation of the HSDP II through its support for the SWAp has contributed greatly to the success attained in the delivery of health service in Tanzania. Different reviews and studies have concluded strongly that the implementation of the HSDP II contributed greatly to the reduction of infant and child mortality in Tanzania. The indicators on infant and child mortality show great improvement and so does the overall capacity for health care delivery at all levels of the health system. Management capacity has been strengthned and clinical care has been strongly integrated into routine health service delivery. Monitoring and evaluation through both routine and systematic surveys has been strengthened; Tanzania MoHSW boosts of having a comprehensive data base on health indicators. These success through are not without challenges especially in human resources for health and funding allocation to the districts given the increasing population and stagnant allocation of resources per capita at district level. These challenges do not in any way take away the success the HSDP II has contributed to improving health service delivery in Tanzania. 25 Table 6: Breakdown of Project Outcome Ratings Objective Achieve improvements in the provision of quality health services through continuing to support the reforms, capacity development and improved management of resources, while placing a greater emphasis on quality. Relevance Substantial Effectiveness Substantial Efficiency Substantial Project Outcome Rating Satisfactory 3.5 Overarching Themes, Other Outcomes and Impacts 62. Poverty Impacts, Gender Aspects, and Social Development: The HSDP 2000-2011 was designed to be socially sensitive to cater to the general population of Tanzania. The positive social impact of the project was its focus on women, children, and other vulnerable groups who were to preferentially benefit from the health services to be supported; its orientation towards the financing and strengthening of district and other peripheral health services and periodic stakeholder consultations through the annual review of sector performance. The project also focused on actions at the household and community level. The social costs of HIV/AIDS were addressed through the MAP projects which run concurrently with this project. The MAP project also addressed AIDS orphans, supported mitigation efforts including those by NGOs and community organizations. The project also focused on improving general health insurance through the NHIF and community health fund. 63. Institutional Change/Strengthening: The overall design of the HSDP II hinges on sustainability and long term institutional strengthening. For Tanzania, the HSDP II and APL II and the two AF have contributed greatly to overall implementation of health and the attainment of favorable health outcomes at all levels. It has contributed to an improvement in human resources for health. Appreciably, even though this area still remains with a number of challenges; the MoHSW has shown great commitment to improving this area which is core to effective service delivery. Another area that has benefited within the institution frame work is the strengthening of both the fiduciary and procurement unit of the MoH. Over 20 procurement officers have been recruited to support the MoH and project specific procurements. Training in financial management and staff recruitment has continued through the life of the project. This has also extended to the regions and provinces. Monitoring and evaluation has been core to the demonstration of results in the HSDP II. This has received great focus for both routine HMIS and specific health and disease peogramme surveys. Capacity building especially for HMIS is still required and this has been recognized given the priority HMIS has taken in the HSSP III. The HSDP II has contributed to overall strengthening of regional and district based planning. This is long term institutional strengthening contributing to better allocation and utilization of resources. Given the nature of implementation of the HSDP II, it has also contributed to streamlining the coordination of implementing health between the MoHSW and PMO-RALG. This is an ongoing process and the HSSP III focuses on strengthening this coordination further. 64. Other Unintended Outcomes and Impacts (positive or negative): The reorganization in Health delivery has highlighted the need for other players within the sector to complement government efforts. The evolution of the PPP, though still having challenges, is creating an environment for growth and diversity in health delivery. The Government should be able to provide leadership through streamlining the process of partnership involvement. This also 26 applies to health financing. The country is barely able to implement NHIF and CHF effectively. The level of disbursement from the NHIF is very low and the CHF is barely functional. The current rate of recruitment of the CHF is less than 30%. This implies that the actual risk protection being intended for communities is not being realized thereby negatively impacting health care access and utilization especially in poor communities. The HSSP III takes this as a priority in ensuring that the processes and activities leading to increased uptake of health financing are favorable and easy to implement. Pay for performance is a vital component for health financing but its implementation has yet to be realized. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 65. Neither Stakeholder workshop nor beneficiary survey was undertaken. 4. Assessment of Risk to Development Outcome 66. Risk to attainment of project development outcomes is rated Low. The major risks as defined on the risk assessment of the HSDP are highlighted in the risk table in the annex. The major ones relate to inadequate human resources for health, lack of government commitment to the SWAp, donor fatigue to the SWAp, fiduciary and procurement challenges. The impact of HIV on the work force was greatly mitigated through the MAP. As the project was implemented it also supported two AF to complement on the budget shortfall and target programme specific intervention both malaria and nutrition. This added another risk on fiduciary management. The project mitigation measures were well carried out as evidenced in the write up; government commitment continued with apparent increase in per capita allocation, more partners were welcomed into the basket, the number of human resources trained and recruited was unprecedented, fiduciary and procurement strengthening was done. All legal covenants were adhered to. These actions positively mitigated against many risks identified during project development and contributed to keeping the attainment of PDO outcomes low. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance 67. Bank Performance in Ensuring Quality at Entry: Quality at entry is rated Satisfactory The Project was a continuation from the first APL in the HSDP I 200-2003. The quality at entry of the second APL was rated satisfactory by QAG. The ICR of the first APL was rated satisfactory. The lessons from the first APL were incorporated in the design of the second APL. The process of project development was consultative between GoT and the DP. The risks and mitigation measures of the first APL were amplified and appropriate clauses in the new memorandum of understanding were included especially those that support procurement and fiduciary processes. The results framework was adapted from the HSSP II for which the second APL was supporting as part of the HSDP 2000-2011. M&E was identified as a weakness in the first APL and this was strengthned in the second APL as exemplified by number of health surveys and functionality of the HMIS19. Given the nature of the HSDP, the 19 . It is important to note the HMIS is yet to be fully developed, however the HSDP II contributed to its strengthening and ensure that it received core focus in the development of HSSP III POW. 27 use of APL as the lending instrument was appropriate because of the magnitude of health reforms and the commitment required from both developments partners and GOT. 68. Quality of Supervision: The quality of supervision is rated satisfactory. A Participatory Monitoring and Evaluation (PME) were adopted for the project M&E design. This involved the participation of the key DP, GOT (MoHSW, MOFEA and PORALG) and other stakeholders. As described previously, the M&E for the project was complex not only looking at the results framework indicators but also the implementation arrangement between GoT and the DP. To this effect, a number of working committees were formed that facilitated the review of different aspects of implementation of the HSDP. The MTEF and HSSP II provided a framework for assessing project implementation progress. The project was also monitored through quarterly Basket Finance Committee meetings, Annual Health Sector reviews, the SWAp and Basket Fund (BFC), the annual review of comprehensive plans, annual reports submitted by 133 councils. In addition to the administrative monitoring of the project, sector wide monitoring on attaining intervention specific outcomes was done through the routine system as well as through the specific surveys. The project was a category “B� for environmental issues and mostly focused on the implementation of safe medical waste disposal. The project revised the management of safe medical waste in 2007 and was monitored as part of the overall sector monitoring. 69. Justification of Rating for Overall Bank Performance: In view, of the satisfactory quality at entry and satisfactory quality of supervision overall Bank performance is rated Satisfactory. 5.2 Borrower Performance 70. Government Performance: Government Performance is rated Satisfactory. The HSDP 2000-2011 was the MoHSW sector programme for delivery of health in the country through the HSSP II supported by the PRS. The implementation of health interventions and other cross sector activities of the HSDP II at district level were done through the PMO RALG under the Prime Minister office. The GoT‟scommitment to health can be seen through the increased coordination efforts at all levels especially at district level in ensuring that health is part of the broader development agenda. The GoT has annually been increasing the overall allocation to health even though the total percentage for health sector spending has remained almost the same if not decreasing. This could be the effect of population growth and the growing health budget. The overall per capita health expenditure has been gradually increasing from 8.98% in 2005/06 to 9.63% in 2008/09 and 12.31% for the 2010/11. Implementation of the vertical programmes such as malaria and HIV has been integrated at health facility. However, challenges still remain in optimizing this coordination at all levels. Government and PMO-RALGs commitment of strengthening council level health services, supported by the upgrading of staff skills, and coupled with some improvements in centrally provided services (and the contribution of strengthened national vertical programs) show GOTs commitment to ensuring the HSDP was successfully implemented. These actions underscore the commitment of government to prioritizing health. The GOT as part of the commitment agreed not to move to the PRSC given the fact that the condition of increased and sustained government allocation to the health was not entirely met at the time that the shift was to occur. 28 71. Implementing Agency or Agencies Performance: Implementing Agencies performance is rated Satisfactory. The MoHSW, PMO RALG (LGA) and MOFED were the main implementing agencies of the project. Commitment was very high within MoHSW as was evidenced by the creation of the Health Sector Reform Secretariat which was the secretariat to the SWAp; the participation and leadership in the many different committees that were formed to support the implementation and monitoring of the project. The Sector-Wide Approach Committee, chaired by the PS/MOH, provided a forum for coordination of all the donor-assisted activities/programs (both joint and parallel financing) in the health sector. In addition MoHSW continued to ensure that all recommendations from the DP through the various committees were addressed. This is recognized from the efforts made in improving the level of compliance to meeting different legal covenants especially as regards to fiduciary and procurement issues. The Agencies ensured that SWAp was effectively implemented, coordinated and that the project met all its legal convents albeit with some challenges in the early years of the project implementation. There was strengthened monitoring through, the increased number of reviews and surveys to document evidence of what was happening on the ground. 72. Justification of Rating for Overall Borrower Performance: Borrower Performance is satisfactory due to the fact that the project was very challenging, with complex implementing arrangements. Both GOT and the Implementing Agencies substantially performed in ensuring the success of the project as evidenced by the ISR Ratings (see data sheet), achievement of good indicators in almost all programme areas designed to show progress notably reduction in both childhood and maternal mortality rates(annex and data sheet), improvement in immunization and family planning methods including the improvement in pro poor hospital access as evidenced by further reduction in the ratio of the IMR of the poorest to highest quartile. The challenges experienced in procurement and fiduciary management especially in the start of the project were noted but these by the end of the project were fully overcome. In addition, health in Tanzania is implemented in a multi-sectoral manner, through different line ministries and structures at different levels; the effort of coordinating this level of complexity to attain the evidenced results is in itself a remarkable achievement. 6. Lessons Learned 73. The HSDP II has been contributory to overall health strengthening in Tanzania. Its design and implementation GOT owned and supports key interventions of the HSSP II. Through the implementation of the project, a number of project specific lessons have been established. Below are some of the lessons that were learned. The Health SWAp: a) At the time of project implementation, the SWAp contributed to greater sector coherence and consistency, which secured higher levels of both domestic and external financial resources for health throughout the implementation period. Compared to the set of loosely or non-coordinated projects and programs previously in place, SWAp delivered real improvement in sector coordination and dialogue. 29 b) The SWAp through the implementation of the HSSP has led to the strengthening of joint annual review and a strong Inter ministerial involvement. (MoHSW, PORALG, Ministry of Local government and other line ministries. This was especially important for the SWAp to function effectively in a decentralized manner given that the provision of health care at district level is through local government. The management of the SWAp has brought financial discipline given the collective decision making required from the Health Management Teams at Regional and District level. The District Basket contributes to efficient implementation of health services to ensure effective delivery at district level where the basket is seen as the most reliable source of funding for operations. But the SWAp and basket partners focused their dialogue much on the MOHSW, even for issue of resource management and implementation in the district which are the prime responsibility of the PMO RALG. c) The SWAp has contributed to the alignment of both DP and Government budgeting and accounting through a single system thereby contributing to a reduction in transaction costs. d) Central, Programmatic and SWAp funding are essential for implementation of health services in raising health indicators as exemplified by funding for NMCP Nutrition and HIV/AIDS program. Role of discretionary resources: e) Non-salary, discretionary resources at local/facility level seem to have played a critical role in the results attained. It is an important lesson as we continue to consider supporting such resource allocations. Human Resources for Health: f) Even though Human resources for health remain a challenge in terms of numbers, the SWAp has contributed to increasing both the numbers of qualified DMO and other health officers through extensive capacity building efforts. However, it is evident that capacity building alone will not meet the need of the MoHSW except through collaborative efforts with the civil service department of planning and the implementation of policies that favour work and retention of officers in the civil service. The challenges need to be more thoroughly appreciated, as repeatedly we set targets that rely too heavily upon improved HRH and which aim for improvements which may be unrealistic Health Sector Development g) Strengthening of Client Systems: The implementation of the SWAp through the HSSP II contributed greatly to the design of HSSP III. The goals and target indicators of HSSP III are derived from HSSP II within the context of continued implementation of the SWAp. It has allowed the prioritization of health care delivery and ensured that those areas that did not fully progress within the HSSP II were prioritized in the HSSP III. 30 Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 74. First foremost we extent our gratitude to the World Bank for the support they provided to the HSDPII and as it was supporting the HSSPII its extension and initial activities of HSSPIII. • The Original Project Development Objectives are spelled out clearly and are the same as the one in the original jointly approved signed document. They were never revised except for the number of indicators. • The project was designed to support overall health reforms within the context of SWAp. We agree that the design had great strengths in taking health as close to the people as it was implemented mostly by the districts through the process of devolution. It broadened the interactions between various implementers such as MOHSW, MOF, PMORALG, Private and Donor community. • The design emphasised Govt ownership of programmes, focused on building the health systems and capacity away from the vertically managed donor projects. • We agree with the assessment outcomes on effectiveness and relevance of objectives, Design and implementations. • On the health sector financing particularly at District level the report says of mostly reliance on health basket; irregular disbursement of bloc grants, ceiling tied with the disbursement make rational management of resources difficult. Inconsistent of medical supplies from MSD this needs to be addressed or rather explained. • Results Framework analysis shows that all the 6 PDO indicators their target values were achieved. While the intermediate outcome indicators only five out of 23 indicators did not meet the targets. These results can be compared with the ones from the Govt prepared ICRR document so as to avoid inconsistencies. (b) Co-financiers 75. None (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society) 76. None 31 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) IMPROVING DISTRICT LEVEL 38.74 101,112, 289.75 261 HEALTH SERVICES (59.6%) STRENGTHENING THE MANAGEMENT OF HOSPITAL CARE & CENTRAL SUPPORT TO 26.26 68,539,203.12 261 QUALITY, FINANCING & HUMAN RESOURCES (40.4%) Total Baseline Cost 65.00 169,651,492.87 261 Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 65.00 169,651,492.87 261 Front-end fee PPF 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing Required 65.00 169,651,492.87 261 (b) Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Cofinancing Appraisal (USD millions) (USD millions) Borrower 350.00 2 829.00 808.28 International Development Association 40.00 140.00 350.00 (IDA) IDA GRANT FOR POOREST COUNTRY 25.00 29.61 118.8 Bilateral Agencies (unidentified) 548.00 986 180.00 32 Annex 2. Outputs by Component Main Objective: 77. The long-term objective of the Program (2000-2011) is to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women, and children. Health Structure and implementation: 78. Tanzania has 21 administrative regions that comprise 113 districts, 133 councils, and approximately 10,342 villages. The overall health service delivery structure is comprised of PHC services, public and private health care providers, as well as council health services, Regional health services and national services. Health services in Tanzania are delivered through a decentralized system whereby local Governments (under the Prime Minister‟s Office–Regional Administration and Local Government, or PMO-RALG) are responsible for service delivery through dispensaries, health centers, and district hospitals. It was noted that the implementation of the decentralization policy is still the subject of major efforts under the Local. 79. Tanzania has a total of 4,679 dispensaries and 481 health centers, located throughout the country. There are 18 regional hospitals that take referrals from the 55 GOT-owned district hospitals, 13 FBO hospitals, and eight consultancy and specialized hospitals, also spread across the country. In addition, there are 86 GOT-owned, parastatal, and private hospitals at the first referral level. 80. The MOHSW collaborates closely with PMO-RALG and the LGAs, which fund and oversees all district-based health activities. The MOHSW relies on LGAs to implement new policies, allocate resources, deliver health services, and provide health data. In addition to working with LGAs, the MOHSW also collaborates with several other ministries: the Ministry of Finance and Economic Affairs (MOFEA) that provides funding, and the Ministry of Higher Education, Science and Technology (MHEST) that trains health workers. Government Reform Program II was developed to iron out lingering challenges in the separation of roles and responsibilities between PMO-RALG and other ministries, including the MOHSW. It was pointed out that a number of challenges in coordination and implementation at LGA exist and efforts were being made through various government initiatives (some with development partner support) to strengthen LGAs‟ ability to deliver services by improving their management capacity, programmatic and financial accountability and to streamline working relationships between ministries. Delivery of health care at different levels: 81. Central Levels: The central level provided guidance through the development of relevant policy guidelines and documents. It lobbied for increased health funding with the result that overall health financing increased over time. The total health expenditure as a percentage of GDP shows an increase from 3.8 in 2004 to 6.8 in 2008, which for 2008, was over the sub Saharan Africa average of 5.6 and low income countries group of 5.1. There has also been an 33 increase in per capita health expenditure over the years from 7.42 in 2004/05 to 13.46 in 2008/920. In addition the central level contributed to increased recruitment and training of health workers across all levels, strengthened supervision to regional and district levels and also providing support for monitoring and evaluation. 82. Regional Level: The Regional Health Management teams have been strengthened and are responsible and hold accountable Council Health Management Teams (CHMT) within the health system. CHMTs prepare the CCHP on an annual basis; these plans hold the CHMTs and their councils accountable to the central health authority and their constituents. Regional capacity has been strengthened with increase in human resource capacity building, and provision of technical assistance to the CHMT , the strengthening of the inspectorate function, performance audits, introducing a quality assurance program (including client satisfaction assessment), supporting districts in data collection, data management and decision-making, strengthening district capacity for Supportive supervision and facilitating inter-district exchange of experiences. However, even though the Regional levels can be said to be have done well in supporting the districts and other lower levels, the regularity and frequency of this support was poor. In addition, the regional levels themselves have challenges in capacity and this also affects the quality of supervision provided to districts. Human resource availability remains low and the availability of funds outside the health basket to support monitoring activities is very minimal. 83. Improved District Health Services: The district level is the focal point of health care delivery. All health services that impact on national indicators especially the MDG/MKUKUTA targets are implemented at this level. The district level benefited from increased funding and capacity strengthening. Over the lifetime of the project, district health funding increased from $0.50 per capita to $2.50. All District Medical Officers in the country are Public Health trained. The District Medical Officers (DMOs) develop work plans with the support of the Council Health Management Team. The DMO also runs the district accounts and manage resources from the health centers. District health is implemented through the Councils and the Ministry offers only supervisory and technical expertise. Even through funding of vertical programmes remains earmarked with significant vertical implementation of specific program actions, the implementation of such programs at district level uses the structure that have been put in place to support delivery of health care, through health centres and community health posts. Implementation of curative health services is well integrated. 84. Zonal Training Centers (ZTC): A number of zonal centers of excellence were established across the different zones in Tanzania. The ZTCs helped train all CHMTs and RHMTs in using the CCHP planning guidelines. ZTCs are offering short courses in Council Health Management, Integrated Management of Childhood Illnesses, and also guidance to develop business plans. The challenge remains as inadequate funding and number in training staff hampers the effective implementation ZTC activities. Especially the lack of resources to conduct onsite monitoring activities of the Council Health Management teams in their catchment areas. 20 MOHSW.2009d. Health Sector Public Health Expenditure update. 2008. Dar es Salaam. 34 Health Systems and Disease Programmes 85. Malaria: The NMCP was supported through the first Additional Financing of 2006 (over 40 percent - US$25 million of the Additional Financing). Support was mainly for the procurement of LLINs and retreatment kits Results show that scaled-up efforts to prevent malaria have led to confirmed reductions in malaria incidence21. Prevention efforts have relied mainly on the use of insecticide-treated bed nets (ITNs), which has substantially increased over the past several years. Through this process the NMCP was able to raise coverage of ITN/LLIN home ownership from 39.2% in 2007/8 to 63.47% (draft 2010 TDHS), utilization of in children less than 5 years increased from 25.7 (2007/8 -MHIVIS) to 64.1% (Draft TDHS 2009/10). Malaria treatment remains a preserve of the broader health system and has been integrated in the normal health facility related activities of health care delivery. Progress in this area is also noted as evidence from the result shown in table 7 below. The NMCP resource comes from direct central financing and other partnerships support like the GFATM, bilateral and multilateral agencies. The Bank financing for the first AF (2006) was meant to meet a specific need for improving the availability of ITN treated with insecticide. Figure 13: Progress Coverage and Utilization of LLINs/ITNs Table 7: Progress on Malaria Treatment Indicator 2009/10 2007/08 HIV/Malaria TDHS Indicator survey Proportion of children with fever two weeks before the survey 59.1 56.7 who took anti-malarial drugs. Proportion of children with fever two weeks before the survey 39.0 34.3 who took anti-malarial drugs same day. Proportion of children with fever two weeks before the survey 37.5 - who took ACTs Proportion of children with fever two weeks before the survey 26.2 - who took ACTs same day. Proportion of children with fever two weeks before the survey 16.2 - who had blood taken. Source: TDHS 2010 (preliminary) 86. HIV: The MoHSW working with its sister ministry of PO-RALG established treatment centers in all districts in the country. VCT services are readily available at health centre level. Treatment centers are found in all tertiary and most district hospitals. Some health centers with adequate staff are also able to offer HIV counseling and treatment services. The availability of laboratory equipment in district hospitals and health centres is hampering the establishments of treatment centres. HIV services have been integrated and are being supported by both direct 21 Ministry of Health and Social Welfare. Health sector performance profile 2009 Update. Main land Tanzania July 2008-June 2009. Dar es Salaam. 35 central levels financing as well as support from bilateral and multilateral donors. The broader sectoral wide implications of HIV/AIDS implementations remain as a strongly vertical activity. Community HIV interventions go on as part of district outreach services within the broader context of community health delivery. Table 8 highlights the progress in a number of HIV core indicators. The increase of ART coverage and HIV testing services is evidence to the integrated activities district and health centre level. Table 8: Progress in HIV Interventions Indicator Proportion Data source Year ART coverage among people with advanced HIV infection 14% WHO 2006 80% NACP 2010 Pregnant women tested for HIV during antenatal visit 27% DHS 2004/05 79% MOHSW 2008 HIV Prevalence among 15-24 year old pregnant women tested 6.8% NACP 2005/06 HIV Prevalence among 15-24 year old population male/female 3.6% (F) THMIS 2007/08 1.1% (M) HIV prevalence among 15 - 49 years old population 6.8% (F) THMIS 2007/08 male/female 4.7% (M) Source: HIV and Malaria Indicator survey; 2007/8 87. Reproductive Health Implementation: The second AF contributed to the financing of improving Reproductive Health indicators through procurement of obstetric equipment. The current picture is one of increasing utilization of health facilities for delivery as indicated by the percentage of births delivered by skilled personnel of 43.4% in 2005 (WDI) to 51.0% shown in 2009/10 TDHS even though this still remains sub optimal. Less progress has been observed in total fertility rate (TFR) reductions of 5.8 seen in 2007/08 (HIV/Mal S) and 5.4 in 2009/10 (TDHS) of which further improvements requires concentrated government attention. The emergency obstetrical care (EmOC) equipment included in the additional financing should contribute to improvements delivery in health facilities. For contraceptive practices indicators, the overall uptake in Tanzania is increasing from 26.4% in 2005 to 34% in 2009/2010 TDHS. The apparent dichotomy between contraception rate increase and the relative little decrease in fertility rate is can be attributed to a combination of factors; behavioral, social economic and cultural. Figures 14 highlights progress in RH intervention indicators. Injection, condoms and the pill remain the main methods of choice. ANC first attendance is generally very high with those meeting criteria for focused ANC at 61.5%. Figure 14: Progress on RH Interventions 36 88. Figure 15 shows progress in hospital delivery by region. The proportion of health facility deliveries across regions will country average of 52% in 2008 an increase of 1.996 percentage points to that of 2007. The national average clearly shows there is need for more effort in improving uptake to over 60%. With increased uptake of ANC before 16 weeks gestation, it is more likely that it will contribute to increase in health facility deliveries. This however, will depend on the level of community confidence the community has in the facilities. Figure 15: Percentage of Deliveries in Health Facilities Source: MOHSW, 2009, Health sector performance review Report 89. Nutrition: The project provided funding support to strengthen central level fortifications of micro nutrients and the strengthening of the Nutrition and food commission. Reductions in malnutrition are on track to be achieved as shown from the Figure 16 below. Vitamin A supplementation exceeded the target 50%. Current level is 60.3%. The commission developed policy guidelines for both private sector and public sector involvement in fortification activities; these guidelines have been finalized and gazetted. The actual fortification process was challenging due to Government of Tanzania and private sector disagreement on modalities of implementation including the fortification processes, type of fortificants to be allowed, micronutrients premixes to be used and development of the nutrition policy. This stalled the procurement process and hence the AF financing could not dispense fully during the time of the project. The National fortification programme benefitted greatly from the HDSP II and will contribute to Tanzania being the one country in east and central Africa with the highest number of fortifying industries. Figure 16: Progress in Nutrition Interventions (TDHS 2009/10) 90. IMCI and Immunization Activities: This has increased tremendously across the country from the baseline levels. Targets for DPT –HB3, BCG, and measles have essentially been met. 37 DPT coverage shows an increase from 83% in 2007(WHO) to 88% in 2009/10 (TDHS) Even though the target MDG 2015 of 90% was not attained, achievement of 88% is substantial progress towards attainment of MDG 2015 target. Figure 17 reflects the yearly trends in DPT- HB3 immunization. IMIC is being implemented in all districts and is contributing to rational management of childhood illness at community level. The community component of the IMCI is contributing to improving community knowledge on health seeking behavior especially the management of malaria and other febrile illness at community level. This again exemplifies the scaled up activities of health service delivery at district level and in communities. Figure 17: Progress DPT-HB3 Immunization Source EPI Programme MOHSW 91. Tuberculosis (TB): The program has surpassed the global target set at 85%. . This is an improvement from 2007 where the rate was 84.7%. The current rate of 87.8% is excellent thought it poses challenges especially in ensuring that this level of success is maintained. Figure 18 highlights the regional rates and total. The progress is entirely uniform signifying the program conceited efforts at moving the implementation of TB interventions in all Tanzania. In addition this provides evidence for the system‟s capacity to deliver within the context of the SWAp. Figure 18: TB Treatment Success Rate by Region Source: Health sector performance Profile update 2009 92. Medicines Procurement Supply Management: The majority of medicines and supplies (90 percent) are procured using the government budget (including budget support from 38 development partners) through the MSD. Approximately 53 percent of medical products were procured with government funding in 2006-2007. The remainder of the medical products, particularly those funded through non government sources, is procured through international procurement agents. The MSD follows the Public Procurement Act no 21 of 2004, procuring through international competitive bidding. The processing time takes approximately 9-12 months. The MSD‟s procurement functions have been assessed by the Tanzania Public Procurement Regulatory Authority, as well as by the Global Fund, both provided very positive reviews. Health facilities then draw their drugs from the MSD as per allocation from central government. When this allocation is exhausted, the facilities have to procure from outside using block grant and/or user Fees and from the district health basket which by the close of the project had an allocation of $0.25 per capita for medicines and other medical supplies. Figure 19 shows the distributors of pharmaceuticals in Tanzania. Figure 20 highlights the availability of commonly used medicines by type of health facility. Figure 19: Distribution of Pharmaceutical Products in Tanzania Figure 20: Availability of Medicines by Type of Facility Source: HSA Report 2010 (draft) Figure 21: Selected Stock out Rates for Common Pharmaceutical Products Source: 2010 HAS Report 39 93. Overall, it should be noted that the HSDP II supported the strengthening of health systems. This facilitated in the delivery of interventions at all levels in an integrated manner. The results from all the vertical programmes and the effort made by the different health care providers and the coordination of the different ministries especially at district level emphasize the synergy which the HSDP II provided in harmonizing implementation and ensuring that key health interventions are integrated within the overall health system. The HSDP II actualized the implementation of the HSSP II and significantly contributed to the successful attainments of PDO and other health indicators. Through the HSDP II the HSSP III was initiated to ensure continuity in the scale up of health interventions and the strengthening of the SWAp. Summary on Outputs by Component 94. Component One: Improving District Level Health Services Objective: Improve District Level Health Services Activities:  Implement quality assurance program (management, training, supervision);  Emphasizing the defined essential health interventions package through the council planning, budgeting and reporting process.  Integrate specified HIV/AIDS activities into service delivery at all levels: district hospital, health centers, dispensaries, ward and village level.  Enhance health promotion activities through multi-sectoral networking at district and Ward level, and increase advocacy for healthy household and community behaviors through dispensary and health centers.  Include epidemics preparedness and response in district planning and management;  Environmental and occupational health management including health care waste management.  Based upon the skills assessment which will be done at regional level, districts will develop human resources in-service training plans.  Strengthen approaches to service agreements (ie, contracting with NGOs and private sector).  Facilitate the establishment of Health Facility Committees and the Council Health  Increase accountability by publishing annual district health budgets and informing facilities about their annual budgets.  Publish annual district health performance data, and discuss with health staff and communities.  Improve equity of resource allocation: Ensure fairness in resource allocation in terms of equity.  Support District Hospital rehabilitation. Outputs on Improving District Level Health Services  All 116 districts managed by qualified DMO with Public Health.  All districts and `133 councils using CCHP as basis of resource allocation and activity implementation. 40  Almost all Councils and Districts have Financial Management Committees that define how council resources are used.  Regular AUDITs of council as per MOU between central government and councils is conducted.  Some council have started the process of publicly displaying the financial management reports through public media.  DHMT prioritizes training through both in-service (seven zonal centres) and on the job training.  Council and DHMT coordination meetings as part of overall coordination taking place regularly at least monthly.  The use of treatment protocols and guidelines and increased number of trained staff in institutions helping in improving delivery of quality of care.  PPP still a major challenge but a number of new health facilities being registered through the initiative.  Implementation of the CHF still a major challenge but some council especially those under the WB pilot scheme moving forward.  Epidemic and preparedness control plans part of the CCHP.  District Hospital rehabilitation being financed through both block grants and basket funds. Basket funds seen as most reliable source for rehabilitation works. However districts are hampered by line item budget ceilings. 95. The DHMT is the focus of health care delivery. Through its structure of health centres and health posts, the general community is able to access health care. The quality of care at the districts is influenced by the leadership provided by the District Medical Officer who administers and supervises all health activities. District funding is through the local council by way of District Health Plans which form the basis for the budget. Implementation of all activities at district level is totally integrated from the hospital through to the health centres. This activity is under LGA authorities with supervision from District Health Boards. The MoHSW provides a coordination, supervision and monitoring of activities in health. Community Health agents at health centre level provide the community prevention and behavior change activities. MCH, Malaria, HIV, and TB actions are all provided as one long continuum of care. The HSDP II through the implementation of the HSSP II contributed significantly to improving the delivery of service at district level. It is important to note that overall district performance has greatly improved as evidenced from the number and quality of reports reaching the Central level from the districts. The level of coordination between the districts and the councils has also improved over time. The DMO is an important member of the Council Management Team that looks at development issues in the Council designated area (district) of which health forms a critical component. 96. Component Two: Strengthening the Management of Secondary & Tertiary Hospital Care Objective: Strengthening the Management of Secondary & Tertiary Hospital Care Activities  Develop a cadre of hospital managers. 41  Mitigate the burden on hospital staff of increased work and hazards related to HIV/AIDS.  Accelerate the establishment of Hospital Boards and operationalize the legal framework to support this.  Have Hospital Strategic Plans and Operational plans.  Deliver package o f quality services, as defined by national norms and standards.  Provide specific quality services for HIV/AIDS patients.  Prevention, counseling and support to HIVIAIDS patients.  Improve emergency and epidemics preparedness and response.  Undertake infrastructure rehabilitation and preventive maintenance with a strong local participation element. Output for Strengthening the Management of Secondary & Tertiary Hospital Care  Hospital manager cadre developed in all hospitals.  Hospital management committee formed in all hospitals.  All government hospitals now functioning under Hospital Boards.  Hospital strategic plans providing guidance on funding and implementation of hospital activities.  Hospitals have hospital financial committees which discuss the management of hospital funds.  Increased support from Central level on Hospital monitoring and support supervision visits on going on a regular basis.  All Hospitals providing a package of clinical interventions as defined by national norms and standards.  All tetially hospitals providing HIV treatment, counseling and testing facilities. 97. All tertiary and referral hospitals provide treatment and diagnostic services for HIV and other communicable diseases. Most of the secondary hospitals also able to provide HIV treatment service. The hospital strategic and operational plans are the basis of hospital activity implementation. These define the level of funding and are managed by the hospital management committee. Secondary and tertiary Hospital rehabilitation is being financed through both block grants and basket funds. The strengthening of tertiary health institutions is contributing to providing higher level curative activities. The overall management of the hospital is under the hospital management board. The various hospital management committees are helping in streaming the implementation of priority hospital activities and the provision of quality care. Hospital financing and utilization of hospital grants is overseen by the hospital financal committee. Hospital financing is done through block grants, user fees, and the health basket. Hospital rehabilitation is undertaken as per hospital plans through block grants and basket funds. Training of various hospital cardres is done through the Ministry of Health central support and cuts across all disciplines. The current level of development in service delivery in both secondary and tertally level hospitals is another example of the HSDP II at work. 42 98. Component Three: Strengthening the Central Level Stewardship Role (standard setting, quality control, financing and human resource development for the sector). 99. Objective: Strengthening the Central Level Stewardship Role (standard setting, quality control, financing and human resource development for the sector. Activities: 100. At District Level:  Provide managerial and technical support to districts on quality service provision including emergency and epidemics preparedness and response.  Enhance performance audit including monitoring of service delivery outputs on a quarterly basis, introduce quality assurance of district health services including client satisfaction assessment and accountability and transparency checks.  Facilitate inter-district exchange o f experiences.  Support districts to strengthen data collection, data management and decision-making improve the performance of the inspectorate function.  Comprehensively analyze skills and human resource needs at district level, training needs assessment of district, in collaboration with Zonal Center. 101. At Central Ministries (MOH and PMO RALG)  Improve health financing, budgeting and the equitable allocation of resources.  Advocate for increased government allocation to health.  Strengthen monitoring and evaluation.  Continue to support Sector Reforms; MOH and PMO RALG to harmonize/streamline planning guidelines through strengthening and harmonizing working modalities between MOH and PMO RALG.  Technical and support capacity is available to councils PMO RALG, CSD and MOH to agree on the composition of the RHMT; and PMO RALG.  MOH will harmonize technical management guidelines.  Strengthen Zonal Training Centers teamwork on continuing education.  Strengthen supportive supervision and of logistical support on regular basis. 102. Outputs Strengthening the Central Level Stewardship Role (standard setting, quality control, financing and human resource development for the sector  Development of guiding policy documents across disciplines. o Malaria o TB o HIV o STI o MCH o Nutrition etc  Strengthening of the HMIS component for data collection and improving the quality of surveys (Malaria /HIV, DHS, etc).  Increasing the human resource base through pre service intakes and in-service training 43  Up grading and strengthening the capacity of qualified medical personnel through further training (MPH and other clinical disciplines).  Strengthening of Zonal centres (6) for in service capacity building.  Strengthening the role of Central to Region, to district supervision for improved performance and on the job training.  Strengthening of the implementation of sector reform as evidenced from the development of the HSSP III to ensure that the gains of HSSP II are sustained.  Provision of technical guidance to council and PMO RALG in the establishment of guidelines and standard for establishment of health teams at both regional and district level. 103. MOHSW has continued engagement with government in advocating for increased resources to meet the increasing demand for financing health care. Government commitment to financing health has continued to be exhibited through continued increase in health spending in nominal terms even though this has fallen short of the 15% Abuja target for health and also reducing per-capita spending, which can be attributed to the increase in the population need as well as the adverse global financial climate. The technical support provided by central level in supporting regions and district councils has helped in ensuring that the devolution of tasks to lower levels continues smoothly. The capacity developed at council in administration and financial management is laying the foundation for future and further devolution of resources to councils. 104. The HSDP II has provided substantial support for the central level to ensure that it provides support to different levels, strengthens the human resource base, and improves coordination among councils and RHMT/DHMT to allow for effective health delivery in a coordinated manner. All vertical programs have well defined objectives, program plans supported by well defined policy documents and guidelines to guide implementation at all levels. The HMIS and LMIS is cardinal to effective delivery of health care as it provides evidence of what is happening on the ground. Tanzania has invested tremendously in the implementation of standalone surveys to complement data that cannot be obtained through the HMIS. The government has also prioritized human resources for health within the health sector to ensure capacity in the delivery of health services at all levels. This is also reflected in the HSSP III as it is pivotal in making sure that services provided remain of good quality. The strengthening of M&E institutions has been cardinal in getting to showcase progress made in the implementing the HSDP II. 44 Annex 3. Economic and Financial Analysis BACKGROUND 105. A. Economic State: Tanzania has shown good progress in economic growth. Tanzania has a per capita gross domestic product (GDP) of US$623 having almost doubled from 5-years ago. This is partly sparked by the expansionary fiscal policies of 2000 and sustained by strong growth in tax revenues, large debt relief and significant growth in foreign aid. GDP growth rate has however slowed down in recent times (from 7.4% in 2005 to 6.0% in 2010) following the global economic crisis of 2009. Current inflation estimates are at 9.9% having gradually increased since 2005, at which time it was reported at 5%. However, projections show that it will return to mid-2000 rates in the coming years. Current account deficit has increased (averaging at about 9.7% between 2010 and 2013) driven by high imports and is no longer fully covered by foreign aid, and is dependent on foreign direct investment flows. a) Its literacy and labor force participation rate is encouraging. Most of the population lives in rural areas (74%, 2009). 78% of the population above 15 years were employed, and mostly in the informal sector. Literacy rate is at 73% and above regional averages, although enrollment of girls at primary school is high, it declines for secondary schooling. b) However, inequity remains high, as poverty levels have not changed much, as 33.6% (2007) of Tanzania‟s population lives below poverty levels. More poor lived in rural areas: poverty head count ratio was 16.4 in Dar-es-salaam, 24.1 in other urban areas, and 37.6 in rural areas. 106. B. Demographic and Epidemiological Status a) Age dependency ratios are high, and effort required in sustaining fertility reductions. The population is at 43.2 million with a population growth rate of 2.5% in 2010 (having decreased from 3.0% in 2004-5). Total fertility rate however still remains high at 5.4 (2010). Women of childbearing age make up about 21.6% of the population, while children under-14 years make up 47.1% of the population. Aged population (above 60- years) is at 6.3%. Age dependency ratio (an indicator of the economic responsibility of adults in their productive years) is at 107 in 2010, and indicates a high burden. b) Communicable disease is a major cause of morbidity and mortality in the country. Policies and programs are in place, offering cost-effective interventions. c) Public health environment is below regional averages and below averages of other low income countries. Fifty four percent of the population has access to clean water and which is below regional averages (SSA average is 60%) and below countries with comparative incomes (LIC average is 64%). Further, 24% of population has access to improved sanitation facilities. More children were reported to have diarrhea in 2010 (14.5%, DHS) than in 2004-5 (12.6%, DHS), a consequence of low access to clean water and sanitation. d) Malaria is a major public health concern. It is a leading cause of morbidity and mortality, and both children under-5 years and pregnant women are among the high-risk group. About 40% of outpatient care is for malaria treatment. There is an insignificant change in prescription of antimalarials: of children under5 with fever, 60% received antimalarials in 2010, compared to 58% in 2004-5. 45 e) HIV-AIDS is a concern in most of SSA, including Tanzania. HIV and Malaria Indicator Survey in mainland Tanzania and Zanzibar reported that 6% of adults (15-49 years) were infected with HIV, the virus that causes AIDS (2007-08). Knowledge of AIDS is universal but comprehensive knowledge about AIDS is low (48%, 2010). Fifty five percent (2010) of pregnant women were counseled and tested and received results for HIV-AIDS, compared to 9% in 2004-5. 107. C. Health and Nutrition Status The status on health and nutrition progress among children and women is variable. While overall improvements are seen in child health, child nutrition shows little improvement. Maternal health lags behind. A diagnosis shows variable results in health service use and quality. One one-side, immunization coverage is significant, and children sleeping under ITN bednets have improved significantly. While on the other side, public health environment has not improved much and the incidence of diarrhea has increased. For maternal care, although, antenatal care is universal, quality of care is variable across regional and economic lines. Use of health facilities for delivery has changed little overall, and especially not much among the lower wealth quintiles. a) Child health outcomes have improved, while maternal health outcomes show little improvement. Under-5 mortality has declined from 112 (2004-5) to 81 (2010) per 1,000 live births, and is expected to be on track to meet the millennium development goal (MDG) targets by 2015. However, maternal mortality ratio remains high at 454 per 100,000 live births in 2010, and is not expected to meet the MDG targets. b) Nutrition status lags behind among women and children. While anemia is reduced among women and children under-5 years, little change is seen in children underweight status: stunting reduced slightly from 38% (2004-5) to 35% (2010), while wasting increased slightly from 3% (2005) to 4% (2010). Use of iron tablets among children has changed little (from 38% in 2004-5 to 41% in 2010) and use of vitamin A among postnatal women is low (from 20% in 2004-5 to 26% in 2010). c) While use of health services has overall increased, inequity exists by wealth and regional differences. Immunization coverage was already high (81%, 2004-5) and has slightly improved with at least 86% children under-2 years having received DPT3 (2010). More children are sleeping under ITN bednets (from 16% in 2004-5 to 64% in 2010). Less children under-5 years are reporting acute respiratory infection, and of those who show symptoms, at least 71% (2010) seek treatment from a health facility, and this has increased from 2004-5 (51% sought treatment). However, use of skilled personnel or health facility for delivery show little change (47% in 2004-5 and 50% in 2010), and postnatal care although improved over the years remains low (13% in 2004-5 and 31%, 2010). More of the wealthy go to public facilities to deliver (75%, 2010), while more of the poor deliver at home (65%, 2010). The Western zone reports the lowest delivery at a health facility (36%, 2010). d) Quality of care is variable. Among women, use of antenatal care is universal (96% in 2010), and although overall quality of care has improved, it remains variable by wealth differentials and by regions: 62% pregnant women received all the necessary care at the health facility (e.g. blood and urine sample taken, blood pressure measured), while 53% of them were informed of signs of pregnancy complications (compared to 43% in 2004-5). 46 The situation was worse among the lowest wealth quintile (41%, 2010), and in the Lake Zone (39%, 2010). 108. D. Health Finance: Health expenditures in Tanzania is financed through multiple sources: central government budgets through the Ministry of Health and Social Welfare (MoHSW), local government budgets, off-budget payments from development partners, cost- sharing revenue, revenue from public and private insurance, and household out-of-pocket payments. 109. Overall resources in the health sector have increased, mainly due to increased external financing in recent times. Per capita health spending is US$24.50, and total health spending as a percentage of GDP decreased from 7.6% (2002/03) to 5% (2005/06). In 2005/06, 28% of total health expenditure was financed by the public sector, 44% by the development partners, and 28% by the private sector. Household out-of-pocket expenditures took up 25% of total health spending. There has been a significant increase in external financing largely a contribution from the Global Fund, and subsequently a reduction in household out-of-pocket spending between 2002/03 and 2005/06. However, in absolute terms, household out-of-pocket spending increased, while in percentage it decreased from 42% (2002/03) to 25% (2005/06). Figure 22: Total Health Spending by Source of Funds (2005-2006) Source: Making Health Financing Work for Poor People in Tanzania: A Health Financing Policy Note. The World Bank. 2011. Note: The data come from the national health accounts conducted in 2005/06. A. Project Economic Analysis 110. The World Bank financed the Health Sector Development Project (2003-2011) in an amount of $165 million. It is estimated that about 25% of the financing went directly towards strengthening the health delivery system to attend to maternal and child health concerns in the country. The project funds were spent in infrastructure, training, and other recurrent costs to improve health service delivery nation-wide. The economic analysis here only reviews a portion of the benefits accrued from this project, and the results are positive. The economic analysis assumptions were that the use of services improved primarily as (i) quality of care improved (less drug stock outs, more trained and improved access to health personnel), and (ii) distance and therefore access to services improved. 47 a) As many as 50% of infant deaths are in the neonatal age group (first month of life), and among neonates, we generally find sepsis and respiratory distress are the leading causes of death, and this can be attended to at birth or immediately after birth. Among post-neonates, we generally find malaria, pneumonia, and dehydration due to diarrhea as the leading causes of death. b) In the economic analysis, we simulated number of deaths that would be averted for children and for women. Our assumptions suggested that infant deaths and especially neonatal deaths were averted as more births took place at health facilities, and for post-neonates as they received improved care that would reduce risk of ARI, and reduce risk of malaria and as mothers received PMTCT. The incidence of ARI reduced and more children sought care, and this too had a significant impact on infant death reduction. During this period, diarrhea incidence increased and fewer children sought appropriate care, therefore, its effect is lower in reducing infant deaths. Immunization coverage was already high before the project started, and although coverage further improved during the project, it had a small affect or deaths averted. c) Maternal deaths were also averted, as more women received quality antenatal care, and delivered at health facilities, and attained postnatal care within 48 hours of delivery. Maternal morbidity was also reduced as they sought treatment and complied with the treatment protocols (e.g. Vitamin A for anemia). Subsequently, fewer women needed to go for additional health care, and cost of treatment and travel was saved. Women‟s productivity was also improved as they were in better health conditions. d) During the project life, as many as 46,000 infant deaths were averted and 3,000 maternal deaths were averted. While the analysis focuses on infant and maternal deaths, many of these interventions should also reduce infant and maternal distress and morbidity. Consequently, total health benefits, as measured by a composite measure such as disability- adjusted life years would be significantly greater. e) The project reaches a positive net present value (NPV) by 2018 (or in its 13th year after project effectiveness), and therefore the net benefits accruing to the country are maximized thereafter. We find that the internal rate of return (IRR) is positive but reaches the discount rate level by 2019 (or at 14 years from project effectiveness). This is an acceptable investment. Appendix 1 provides the technical specifics of the analysis. Table 10: Tanzania, Demographic and Health Indicators (2004-5 and 2010) Baseline End Target 2004-5 2010 baseline Total Population, millions 33,710,000 43,190,000 Women of reproductive age -% 23 24 - no. 7,753,300 10,365,600 Maternal mortality ratio (MMR) 578 454 no of maternal deaths 8,261 7,620 Crude Birth Rate (CBR) 42.4 38.86 Infant mortality rate (IMR) 68 51 Neonatal mortality rate (NNMR) 32 26 no of infant deaths 97,193 85,597 no of neonatal deaths 45,738 43,637 48 No. of new births 1,429,304 1,678,363 % of births delivered by professionals 46.3 50.6 % of births delivered at facilities 47.1 50.2 No of births by professionals 661,768 849,252 No of births at facilities 673,202 842,538 Source: Demographic and Health Survey, 2004-5 and 2010 111. Table 11 helped assess infant deaths averted. The baseline for the causes of infant death is taken from WHO (2006), and the information on morbidity profiles and use of services is taken from DHS (2005, 2010). We assume that morbidity patterns and health service use patterns affect mortality patterns. Between 2005 and 2010, we find that: (a) diarrhea incidence increased also correlated will less children following appropriate techniques to prevent dehydration, (b) ARI reduced, (c) PMTCT use improved. The increase in use of measles vaccines is very low, and the use of ITN although has changed much, the malaria incidence remains high. For post- neonatal deaths, we assume that improved quality of care will attract more children to receive care at health facilities and post-neonatal deaths will also reduce. Post-neonatal deaths are about 47% (2006) and 51% (2010) of total infant deaths. See simulation on Table 12.3. Table 11: Causes of Death for Infants (2006) Causes of Death Percentage of infant deaths 2005 (%) 2010 (%) Neonatal period 47% 51% neonatal tetanus 3% severe infection 29% birth asphyxia 27% Diarrhea, dehydration 3% Congenital malformation 7% preterm births 23% Other 8% Post-neonatal period 53% 49% HIV/AIDS 12% 6% Diarrhea, dehydration 23% 24% measles 1% 1% Malaria 31% 29% pneumonia 29% 20% Injuries 3% 3% Source: WHO, 2006. Note: 2010 information is simulated by author. 112. Tables 12.1 to 12.3 provide a simulation for child mortality averted. For neonatal deaths averted, the simulation took the following assumptions: (i) quantity of institutional delivery went up, and (ii) quality of service improved, such as use of services for institutional delivery and for user of services. Given the project investments and improved quality of care, we assume that the percentage delivery at health facilities will increase by about 1% per year. Given that we already have results from the DHS for 2010, we find that to be the case. We have assumed that risk of a neonate dying varies by the place of delivery: at health facility risk of dying is 0.012 (2005), while at home risk of dying is at 0.05 (2005). As quality of health facility improves with improved investment, the risk of dying at health facility also reduces (from 0.012 in 2005 to 49 0.007 in 2010). We also assume that the project is able to improve quality of antenatal care (which too is universal coverage) and thereby home delivery has a reduced risk of dying over the years (from 0.05 in 2005 to 0.045 in 2010). Table 12.1: Neonatal Death Model (2005) case=1 (2005) health facility health professionals baseline attended attended not attended Total % childbirth 0.47 0.53 risk of dying 0.012 0.05 total births 671773 757531 1,429,304 Neonatal deaths 8061 37877 45938 Neonatal mortality rate 12 50 32 Source: Author, simulation results Table 12.2: Neonatal Deaths Averted (2006-2011) 2006 2007 2008 2009 2010 2011 neonatal deaths: # facility 7556 7015 6511 5958 5359 4713 # at home 37203 36478 35390 34261 33097 31902 # total 44760 43493 41900 40220 38456 36614 % facility 17% 16% 16% 15% 14% 13% % home 83% 84% 84% 85% 86% 87% NMR 31 30 28 27 26 24 neonatal deaths averted 1721 3478 5551 7657 9787 11933 Source: Author, simulation results Table 12.3: Results of the Economic Analysis for Averted Infant Death (2005-2010) Year intervention Averted infant deaths Number of Years of YLG DALY DALY Post- childbirth Neonatal neonatal Infant lives life gained sum sum attended Saved (NPV) (NPVsum) (NPV) (NPVsum) 2005 Baseline 0.47 2006 0.48 1721 1941 3003 157,276 97,494 2007 0.49 3478 3768 8945 468,523 290,431 2008 0.5 5551 5778 18234 955,138 592,078 2009 0.51 7657 7657 30791 1,612,880 999,804 2010 0.52 9787 9403 46527 2,437,104 4,636,290 1,510,731 2,873,979 Source: Author, results from a simulation 113. Table 12.3 estimates the cost of year of life gained (YLG) is US$ 8, and the cost per disability adjusted life years (DALY) is US$14. A similar simulation is run for maternal deaths averted. Maternal risk of dying when delivering at health facilities is at 0.0011, risk of dying when delivering by skilled attendant (but not at health facility) is 0.0051, while risk of dying 50 when delivering at home is at 0.010. Similar assumptions are made of reduced risk of dying at health facility and under skilled attendant, a consequence of improved quality of health care. 114. Table 13 presents the costs and benefits from the project investment. It shows the savings incurred by death or morbidity averted. For per capita health costs, the NHA per capita health spending for that year is selected. For example, the per capita health spending was US$ 24.50 in 2005, and thereafter an inflationary increase of 3% is taken. For women‟s health, US$100 is taken for health spending savings incurred for mortality and morbidity averted. Further, productivity gained due to improved illness is estimated using GDP per capita as the earnings potential, with an inflationary increase of 3%. The discount rate is taken at 5% while estimating discounted costs and benefits. 51 Table 13: Net Present Value and Internal Rate of Return (2005-2019) Averted for child Averted for mother Total Discount Discounted Project Project Net Discount Discounted NPV IRR year Net Productivity Illness Productivity Illness Benefits rate r= Benefits Costs Benefits rate Benefits Loss, $ Cost, $ Loss. $ Cost, $ $ 5% (MNCH) $ $ 5% $ % 0 1 3,250,000 (3,250,000) 1 (3,250,000) 2005 73,562 (28,662) (6,901) 38,000 1.05 36,190 3,250,000 (3,212,000) 1.05 (3,059,048) (6,309,048) 2006 232,487 44,402 10,691 287,579 1.10 260,843 3,250,000 (2,962,421) 1.10 (2,687,003) (8,996,051) 2007 488,169 164,698 39,654 692,522 1.16 598,226 3,250,000 (2,557,478) 1.16 (2,209,246) (11,205,297) 2008 849,070 380,350 91,577 1,320,998 1.22 1,086,788 7,500,000 (6,179,002) 1.22 (5,083,480) (16,288,777) 2009 1,321,457 572,454 137,830 2,031,741 1.28 1,591,922 7,500,000 (5,468,259) 1.28 (4,284,524) (20,573,301) 2010 1,787,617 665,642 165,075 2,618,334 1.34 1,953,841 5,000,000 (2,381,666) 1.34 (1,777,236) (22,350,537) 2011 2,280,558 759,227 193,932 3,233,717 1.41 2,298,142 5,000,000 (1,766,283) 1.41 (1,255,264) (23,605,802) 2012 2,801,466 782,004 199,750 3,783,220 1.48 2,560,632 3,783,220 1.48 2,560,632 (21,045,169) 2013 3,351,576 805,464 205,742 4,362,783 1.55 2,812,289 4,362,783 1.55 2,812,289 (18,232,881) 2014 3,932,172 829,628 211,915 4,973,714 1.63 3,053,429 4,973,714 1.63 3,053,429 (15,179,451) 2015 2,300,586 4,544,586 854,517 218,272 7,917,961 1.71 4,629,468 7,917,961 1.71 4,629,468 (10,549,983) 2016 7,059,000 5,190,207 880,152 224,820 13,354,180 1.80 7,436,107 13,354,180 1.80 7,436,107 (3,113,876) 2017 14,822,308 5,870,475 906,557 231,565 21,830,905 1.89 11,577,395 21,830,905 1.89 11,577,395 8,463,519 4% 2018 25,780,352 6,586,888 933,754 238,512 33,539,506 1.98 16,939,729 33,539,506 1.98 16,939,729 25,403,248 8% 2019 Source: Author, results from a simulation 52 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Wachuka W. Ikua Senior Operations Officer AFTHE Muthoni W. Kaniaru Sr Counsel LEGFI Emmanuel G. Malangalila Consultant AFTHE Doinic Hazeen Lead Specialist AFTHE Julie McLaughlin Sector Manager, Health, Nutrition SASHN Jonathan Nyamukapa Sr Financial Management Specialist AFTFM Oscar Picazo Consultant EASHS Pascal Tegwa Senior Procurement Specialist AFTPC Supervision/ICR Emanuele Capobianco Sr Health Specialist. SASHN Serigne Omar Fye Consultant C3PDR Johannes G. Hoogeveen Senior Economist AFTP2 Wachuka W. Ikua Senior Operations Officer AFTHE Evelyne C. Kapya Program Assistant AFCE1 Christoph Kurowski Sector Leader LCSHD Emmanuel G. Malangalila Consultant AFTHE Donald Paul Mneney Senior Procurement Specialist AFTPC Anne Muuna Team Assistant AFCE1 Karema Saleh Sr Health Specialist ATHE Peter Okwero Sr Health Specialist. AFTHE Oscar Picazo Consultant EASHS Mercy Mataro Sabai Sr Financial Management Specialist AFTFM Eva Ngegba Program Assistant AFTHE Samia Benbouzid Program Assistant AFTHE (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY04 15 57.12 FY05 0.00 FY06 0.00 FY07 0.00 53 FY08 0.00 Total: 15 57.12 Supervision/ICR FY04 4 31.86 FY05 43 149.38 FY06 34 120.06 FY07 37 137.71 FY08 151.75 Total: 118 590.76 Annex 5. Beneficiary Survey Results (If any) N/A Annex 6. Stakeholder Workshop Report and Results (If any) N/A 54 Annex 7. Summary of Borrower's SUMMARY TANZANIA COUNTRY COMPLETION REPORT Health Sector Development Project Phase 11 115. Background: During the 1990s, the health sector in Tanzania faced a period of stagnation. Local health services were characterized by severe shortages of essential drugs, equipment and supplies and deteriorating infrastructure and were plagued by poor management, lack of supervision and lack of staff motivation. The sector also faced stagnating or deteriorating hospital care. There was little cooperation in health service delivery between the public sector, faith-based organizations, and private service providers. Health services were severely under- funded, with public health sector spending at USD 3.46 per capita. There was also little coordination of support to the health sector by Development Partners. The Government of Tanzania and Development Partners responded to this situation together in a process beginning with a joint planning mission convened by the Government in mid-decade. By 1999, this process resulted in the first major health sector strategic plan, the Health Sector Program of Work (POW) and an agreement that support to the health sector would take place in the framework of a Sector Wide Approach (SWAP). The POW and subsequent Health Sector Strategic Plan 2 (HSSP2) articulated a process of health sector reform aimed at addressing the recognizable deficiencies in the sector and achieving specific goals and targets in health as set out in the Millennium Development Goals (MDGs) and the National Strategy for Growth and Reduction of Poverty (NSGRP)/MKUKUTA). 116. Health Sector development Program: A three-phase, long-term (2000-2011) Health Sector Development Program (HSDP) was jointly developed by the GOT and development partners and was supported through a Sector-Wide Approach (SWAP). The long-term objective of the Program (2000-2011) was to improve access, utilization, quality, and financing of health services through increased efficiency and effectiveness in use and allocation of resources, to maximize impacts on health outcomes, especially among the poor, women, and children. 117. HSDP Phase 1: The objective of Phase I (2000-2003 with an estimated cost o f US$654 million supported by a Credit of US$22 million) was to improve resource management and the quality of health services through sector reforms and institutional capacity building. The Phase I project focused changing the way the sector was managed and financed, and by shifting roles and responsibilities. Particular achievements were made in decentralization, institutional capacity and improved resource management. 118. HSDP Phase 11: The Word Bank provided credit to the United Republic of Tanzania for the support of Health Sector Development Project Phase 11 from July 2003 to end of June 2011. The objective of the phase II project was to achieve improvements in the provision of quality health services through continuing to support the reforms, capacity development and improved management of resources, while placing a greater emphasis on quality. The HSDP II Project supported the Second Health Sector Strategic Plan (HSSP II). The Second Phase of the Health Sector development Program (HSDP II) continued to addresses constraints for effective I implementation of the health interventions - namely, sector financing, human resources, logistics, management and information systems, quality assurance, decentralization and the role of the 55 private sector. The estimated cost at the time of project design was US$963 million, of which IDA was to finance US$65 million. Of this, US$ 40 million was IDA and US$ 25 million grant. The project had two Additional Financings from 2007-2009 for IDA US$60 million and the second AF for 2009-2010 for IDA US$ 40 million. The total HSDP IDA financing was US$165 million (original US$65 million and US$l00 million AF), with US$125 million or 76% going to the Health Basket. As for Phase I Project, Phase II was implemented by the Ministry of Health (MOH) and the District Councils under the President's Office, the Regional Administration and Local Authority (PMO-RALG). Other vertical programs which benefited from this grant were malaria, HIV/AIDS and Nutrition and Reproductive Child Health. The project description was derived from the MOH Second Health Sector Strategic Plan 2003-2007. This Plan was appraised and endorsed by stakeholders at the Annual Review in April, 2003. Phase II o f this APL was to support the first 4 years of the Strategic Plan. After that, the Bank‟s support for implementation of the Strategic Plan and the associated MTEF would continue through the PRSC combined with knowledge transfer, policy advice, analysis, and monitoring of both implementation and results. 119. Components of the project: The Second phase of HSDP continued to address the constraints to effectively implementing the defined package of cost effective interventions that are expected to respond to the leading causes of morbidity and mortality in Tanzania. These constraints include sector financing, human resources, logistics, management and information systems, quality assurance, decentralization and the role of private sector. The HSDP 11 was to support three components briefly described below. a) Improving District Level Health Services: To improve the quality of health services delivered at this important level of implementation by Implementing quality assurance program (management, training, supervision), emphasizing the defined essential health interventions package through the council planning, budgeting and reporting process, Integrating specified HIV/AIDS activities into service delivery at all levels, enhancing health promotion activities through multi-sectoral networking at all levels. b) Strengthening the Management of Secondary & Tertiary Hospital Care including human Resources: In this component the focus was to develop a discipline and a cadre of hospital managers. Accelerate the establishment of Hospital Boards and operationalize the legal framework to support this. c) Strengthening the Central Level Stewardship Role: The Central level that includes the MOHSW and the PMORALG and the Regional levels are responsible for standard setting, quality control, financing and human resource development for the sector. o strengthen the Regional Level to be able to support quality of services at district level by providing managerial and technical support to districts, including emergency and epidemics preparedness and response. Support districts to strengthen data collection, data management and decision-making. Strengthen Stewardship Responsibilities of the regions by improving the performance of the inspectorate function and comprehensively analyzing skills and human resource needs at district level, training needs assessment of district, in collaboration with Zonal Health Resource Centers. At Central Ministries (MOH and PMORALG) included improving health financing, budgeting and the equitable allocation o f resources, Advocate for increased government allocation to health and Provide support to strengthening management of cost sharing, CHF and health insurance schemes. Further focus was to address the Human Resource crises by improving long-term manpower planning and invest in greater production o f staff 56 distribution, motivation and retention. Institutionalize network of Zonal Health Resource Centers. To improve the quality of health service delivery: and promote Public-Private Partnerships. To strengthen monitoring and evaluation and continue supporting Sector Reforms. 120. Other significant changes to include two Additional Funding: The program did not change in terms of scope, design, and implementation arrangements and schedule during the implementation time frame. However, the scale was somewhat increased to include more focus on programmatic areas for malaria through the first Additional Financing (AF) and support to the Food Fortification Program and procurement of emergency obstetric equipment through the second AF. The project had three extensions, one 2007-2009 to ensure the completion of the HSSP II and to facilitate the implementation of the first AF, the other December 31, 2009 to December 31, to facilitate the implementation of the second AF and the third from December 31 2010 to June 30 2011 to facilitate the completion of the procurement of emergency obstetric equipment which would increase the proportion of pregnant women delivering in health facilities and ensure that the implementation of the HSSP III was initiated. 121. Implementation arrangements and institutional set up to monitor progress of implementation: As established in the Phase I, in order to avoid parallel systems and foster national capacity and systems strengthening, the Project was implemented within the existing of the MOHSW in the Department of Policy and Planning and PMORALG. The programme was managed and monitored through quarterly Basket Financing Committee meetings which involved senior management from MOHSW and PMO-RALG, as well as donor representatives channelling funds through the Health Basket. The responsibility for oversight and coordination of program implementation rested with the Permanent Secretary MOHSW (PS/MOHSW), in close collaboration with the Permanent Secretary, Prime Minister‟s Office Regional Administration and Local Government PS / PMO-RALG). For quality assurance, the CMO took the responsibility for quantity and quality of the outputs. The Health Sector Reform Secretariat (HSRS) managed the project and took the roll of a secretariat. It is important to note here that, there was no programme steering committee which is generic to projects with Project Implementation Units (PIUs) and separate management teams. The Chief Accountant of the MOH over saw all accounting and financial management under the project/program and the Director for Administration and Personnel for reviewing the procurement of goods, works, and services. Most of the funds went into the pool and a small amount remained outside the pooled funds such as the National Health Insurance, the central component o f the Community Health Fund, and malarial control through ITNs and insecticide re-treatment of nets. The management of the IDA funds outside the pool followed the conventional method through a Special Account. A Joint Annual health Sector Review (JAHSR) every year, preceded by a technical review, assessed actual expenditures and achievements over the year against the plans. Reviewed the MTEF for the coming fiscal year, including financial audit for the previous year and the procurement audit as of December 3 1 o f previous year. This was consistent over the years and there were 7 JAHSR over the life span of the programme. 122. Lending agreements and how this was implemented: The lending arrangements were an Adaptable Programme Lending (APL) loan 40mUSD and a grant 25m USD with subsequent two Additional Financing which finally led the programme to have financial outlay of USD 165 57 m at the end of the programme. The condition to access the loan should be to exhaust first the grant, which was done. 123. Adherence to the legal covenants: No disbursements will be made into the pooled funds account until a MOU has been entered into among the Borrower, the Association and the other Donors contributing to the Pooled Funds. These conditionalities were fully adhered to as indicated bellow. 1. The government organized a joint annual review in March-April and later on in September-October of each year to review the progress of implementation as well as a plan and budget for the subsequent year. 2. The government submitted to IDA and other development partners at least 4 weeks before each annual joint review: (a) an annual report on implementation progress, expenditures, and results of any technical reviews; and (b) a plan of action for subsequent year. 3. On a quarterly basis, the government; (a) submitted to IDA and other development partners‟ reports on implementation progress and expenditures, and (b) organize basket financing committee meetings. 4. Annual financial audit reports, carried out by an independent Auditor, submitted to IDA and other development partners within six months after each financial year. 5. Annual external procurement audit reports submitted to IDA and other participating Partners after each financial year. In addition to the formal annual audits, ad-hoc procurement reviews were conducted by external firms. 124. Overview of implementation of the HSDP II: The implementation progress of the entire project is described as per component and the expected outputs as per results framework. Critical issues of success and important challenges are highlighted. Later on the Assessment of Government and World Bank performance 125. Component 1: Improving District Level Health Services: The implementation of health services at the district level, a decentralised focal point of implementation of all health services interventions, is guided by the Comprehensive Council Health Plans (CCHP).. The CCHP are developed on yearly basis and funded by all sources of funding at the district level including resources from the prepayments schemes- CHF, user fees and NHIF. Funding includes Vaccines, Medicines, medical supplies and equipment, reagents, TB DOTs, Family planning commodities etc. While, the Block grant and health Basket funds is being allocated according to the Resource allocation formula for the delivery of the health services. The CCHPs are developed using the CCHP planning and reporting guidelines that are in-line with the National Health Policy, Health sector Strategic plans, i.e. HSSP II 2003- 2008 and HSSP III 2009-2015, MMAM, MKUKUTA, National vision 2025, MDGs and National Health Program Strategic Plans (NTLP, Malaria, HIV and AIDS, MNCH, Human resources for Health, Environmental and occupational Health and Sanitation including Health care Waste Management, NTDs, Non- Communicable diseases, etc.) Monitoring of implementation of CCHPs is done through quarterly and annual performance reports. 126. Component 11: Strengthening the Management of Secondary & Tertiary Hospital Care Human Resources: All hospitals have established Hospital Management team with led by 58 Hospital Managers. Hospital Management committee has also been formed in every hospital. All public owned hospital have Hospital Boards. All hospitals have Hospital Strategic and operational plans. Accountability and transparency checks with timely reporting have been ensured by establishing hospital financial committees that discuss the management and utilization of hospital funds. On the service delivery all hospitals are delivering a package of clinical interventions as defined by national norms and standards. All hospitals have taken measures to mitigate the burden of on hospital staff of increased work and hazards related to HIV/AIDS. Provides specific quality services for HIV/AIDS patients that includes prevention, counseling, testing and support to HIV/AIDS patients through established VCT centers. The Central Govt has increased support to hospitals by providing bloc grants and health baskets. The MOHSW conducts training to various hospital cadres. Secondary and tertiary Hospitals infrastructure rehabilitations and preventive maintenance with local participation is being done through bloc grants, health basket and user fees. 127. Component 111:.Strengthening the Central Level Stewardship Role: a. At Regional Level, to support quality of services at district level  RHMT planning guidelines were prepared and are in use.  In collaboration with the Technical Cooperation of JICA, management capacity of RHMT was strengthened through a three years project that ended in March 2011. The second phase of the project is expected to start in November 2011.  (The Government through the MHOSW and PMO-RALG agreed to officially include eight Regional Health Management Team core members as part of the Regional Secretariat staff. To that effect roles and responsibilities of those teams were established and also the organizational functioning structure was set.  RHMTs now support districts to prepare CCHPs. They conduct supportive supervision to follow the implementation. CCHP quarterly reports are assessed by RHMTs after which they compile and prepare regional reports.  RHMTs organize Primary Health Care meetings yearly to allow districts share experiences. b. To Improve Quality of Health Services Delivery: The following are implementation status in quality Improvement of health care delivery:  Revision of the Tanzania Quality Improvement Framework (TQIF) in Health Care to cater for Medical/Clinical Audits, Strategies in clinical care of patients and Patients Centered care.  Developed National Supportive Supervision Guidelines for Quality Health care Services and Infection Prevention and Control Standards.  Ministry has adopted Stepwise Certification towards accreditation (SWCA) of health care services.  The Diagnostic Services Section of the Ministry started to implement SWCA with technical and financial support from WHO and CDC in 2008. 128. Health financing, budgeting and the equitable allocation of resources: The government was the major financier of public health expenditures contributing 64% in 2009/10 with the balance being provided by development partners through basket and non-basket funds. 59 Despite the government remaining the largest source of public spending, external resources provided by bilateral and multilateral agencies have become significant, accounting for up to 36% of the total expenditures in 2009/10 from 30% in 2005/06. Cost sharing revenues have also increased reaching well over TZS 7.8 billion or 1% of the public health expenditures in 2009/10. One would view cost sharing as earmarked government funds to the health sector. The share of public allocation on health to Total Government Expenditure (TGE), including CFS, oscillated around 10% between 2006/07 and 2010/11. However the share of public allocation on health to total government expenditure (excluding CFS) increased from 11.6% in 2006/07 to 12.1% in 2010/11. Table 14: Trends of Nominal and Real Per Capita allocated to Health (2006/07 – 2010/11) 2006/07 2007/08 2008/09 2009/10 2010/11 Approved Approved Approved Approved Estimates Estimates Estimates estimates Estimates NOMINAL 10.71 12.18 13.46 15.00 18.80 USD REAL USD 7.34 8.01 8.63 9.80 10.55 129. The health sector basket allocations to LGAs increased from 0.5 USD per capita in 2003 to 0.75 USD per capita in 2005; then USD 1 per capita in 2007; 1.25 USD per capita in 2008 and in 2010 it is 1.50 USD per capita. In 2011 health basket allocation has reached to 1.8 USD per capita. 130. Insurance schemes: Government has continued to support the management of these schemes. NHIF and CHF both receive funding from the ministry‟s budget, to support capacity building activities especially those with management nature. In 2009 the ministry went a step further by signing a Memorandum of Understanding with NHIF management to grant them power to manage CHF for the period of three years to 2012. The aim is to strengthen management of the Fund. Due to these efforts coverage has increased to in both schemes. It currently stands at 10.8 percent CHF while NHIF coverage is 7.55 percent of September 2011. In general access to health Services has been improved by the increase of coverage of prepayment schemes (NHIF, CHF and TIKA) by 15%. 131. Auditing and Financial Accounting arrangements: The World Bank Project was designed to have three tiers, one following contribution to Basket Fund Holding Account and follow exchequer system for budgeting, accounting and reporting and the second one was separate bank accounts at Standard Chartered Bank (T) Ltd and direct payments by the World Bank. The Project supported the financing and implementation of the Health Sector Development Program as informed by the second and third Health Sector Strategic Plans and the Medium Term Expenditures Frameworks (MTEF) of the MOHSW, PMO RALG and Comprehensive Council Health Plans of all Councils in the country. For pooled funds, the Government and the Development Partners who were financing the Heath Sector Development Program adopted the use of common Government systems including planning and budgeting, procurement, disbursement, accounting, auditing, reporting, monitoring and evaluation. The use of common arrangements by the Development Partners financing the program aimed at 60 strengthening the Government management systems by enabling the Government ownership of the program, enhancing internal capacity, sustainability of the program and reducing burden and transaction costs of multiple procedures. The auditing and financial accounting under the Project were in accordance with the Memorandum of Understanding (MOU) between the Partners (Government of Tanzania and Donors) participating in the pooled funding (“basket financing) of the health sector, the procedures and accounting manual for the basket fund, the Government financial and auditing regulations and the World Bank disbursement guidelines and procedures. 132. Financial Management: The Project used a USD Holding Account (i.e. the joint account for basket fund) which is maintained by the Treasury at the Central Bank of Tanzania. The Development Partners including the International Development Association contributed the funds through the Holding Account basing on their annual commitments stipulated in each year Side Agreement, signed between the Government and Development Partners contributing funds to the basket. For IDA funds outside the basket, the Project used Designated Bank Accounts. The funds were disbursed from the USD Holding Account to the Exchequer, followed the Government disbursement mechanisms. AS per the MOU, the Project prepared various financial and technical reports that were used both internally; to monitor the implementation of the Health Sector Program, assisting in planning and externally to fulfill statutory audit requirements. Most of the financial reports were generated through the Integrated Financial Management System (IFMS). 133. Procurement and Audits: The Audit Sub – Committee chaired by the Government; review the annual audit reports and provides recommendations to the BFC. The committee also monitors the follow up action/measures on the auditor‟s recommendations and report to the BFC. The audit has showed mixed results with yearly improvements. Below is the summary of the audit opinion for the Basket Fund, LGAs and for the non pooled funds provided by IDA from year 2003/2004 to 2009/2010? Procurement continued to be managed by the Procurement Management Unit of the Ministry of Health and Social Welfare and Medical Stores Department. IDA continued to conduct prior reviews for larger contracts particularly those using competitive bidding or international consultant procedures, on behalf of the development partners as per Memorandum of Understanding which governs pooled fund. 134. Progress towards Results and Results Framework. a) Addressing Human Resource crises: Ministry of Health and Social Welfare has been keen in ensuring improvement of the human resource situation described as HRH Crisis since 2003 and beyond. Ministry is and will go on addressing the human resource problems by involving all stakeholders in the improvement of the HRH situation in the country. Various interventions have been applied and a number of achievements have been realized with time as follows: 1) Strengthen Zonal Training Centers and teamwork on continuing education including exploring how to increasingly distance learning; Upgrading program for Nurses through e- learning has been established. e- Learning will provide opportunity for health workers to undertake training on the job to minimize further shortage of skilled personnel at work place. Distance learning centers have been increased from 8 to 16 and various modules have been developed. 61 Developed HRM District strengthening package (includes Training, Coaching & mentoring guide). 2) Public-Private Partnerships: Currently up to 20 councils have contracted out to private facilities to provide health services mainly focusing on MNCH services. PPP fora to facilitate interactions at different levels have been established in some regions and councils. The private sector involvement is crucial in the provision of health services however, there are challenges which include: a. Uncommon understanding of PPC/PPP among key stakeholders. b. Inadequate institutional capacity to implement PPP/PPC at different levels. c. In adequate resources to implement the PPP/PPC. b) To strengthen monitoring and evaluation: Performance audit including monitoring of service delivery outputs at district and referral hospitals. c) Progress towards Service Delivery: Service delivery indicators include outpatient attendance, vaccination coverage, access to reproductive health services, and indicators measuring HIV and AIDS, malaria, tuberculosis and leprosy, infectious and non- communicable disease performances. d) To strengthen the provision o f logistical support through funding of funding of pharmaceuticals and health commodities. e) Food Fortification Program. f) Reproductive Health: Support on Emergency Obstetric equipment. 135. Assessment of Government and banks Performance: The general objective was to improve the provision of quality health services to the Tanzanians. Since the project was managed through Sector Wide Approach (SWAP), and indicators to monitor the project as well as to evaluate it were picked from Health Sector Strategic Plan II. 136. PDO Indicators 1. Total Fertility Rate: The TFR lightly declined from 5.6 in 1999 to 5.4 in 2010. 2. Life Expectancy at Birth: The above figure shows an increase in life expectancy from 52 in 2002 to 56 in 2008 according to prediction. No prediction for 2010 but it is expected that life expectance is likely to have improved due to substantial decline of child mortality. Decline of child mortality has direct influence to life expectancy improvement. This will be confirmed by 2012 Population Census. 3. INFANT Mortality rate: As we can see from the figure, there is a decline in Infant mortality rate from 99(1999) to 51(2010). 4. Ratio of the IMR of the poorest quintile to the IMR of the least poor quintile: The above figure shows the slightly decline in the Ratio of the IMR of the poorest quintile to the IMR of the least poor quintile whereby the IMR declined from 1.29 in 1999 to 1.08 in 2010. 5. Under Five Mortality rate (per 1000): The results from TDHS 2009/10 shows significant decline of child mortality specifically infant and Under Five Mortality Rate from 147/10000 in 1999 to 89/10000 in 2010. 6. Maternal Mortality Rate (per 100,000: The baseline data from TDHS 2004/05, estimated Maternal Mortality Ratio (MMR) at 578 maternal deaths per 100,000 live births. The TDHS results of 2009/10 shows MMR has declined to 454 deaths per 100,000 62 live births. This is a notable improvement but relatively the maternal deaths are still high requiring more effort to attain MDG goal which is 265 per 1000,000 live births. 137. Intermediate Outcome Indicators: 1. Family Planning: Modern Contraceptive prevalence rate has increased from 20% in 2004/05 to 27.4% in 2010 2. Immunization coverage: continues to be high (Penta valent 3 coverage increased from 85% in 2009 to 91% in 2010), however there are regional disparities. 3. Coverage of ITNs Improved: completed under five catch up campaign and universal coverage campaign. 4. HIV/AIDS: A notable decline in HIV prevalence13% in 1980‟s to 5.7% in 2007/08. 5. Care and Treatment; enrolled 749,302 and 390,320 are on treatment, the target is 440,000 by 2012. 93% of RCH clinics provide PMTCT services and 92% of HIV +ve pregnant women receive ARV‟s for prophylaxis. 6. TB .treatment success and case finding has been maintained at high levels. 7. Antenatal care services: only 1/3 of the regions have more than 50% women attending ANC <16 weeks; ANC 4+ visits: urban – rural gap widening. 8. Skilled attendance at birth: majority of regions behind national target (50% of women get skilled attendant at birth) Maternal Mortality Ratio observing a slight decline in maternal mortality ratio we need to strengthen registration of births and deaths. 9. Allocation per Capita: There is an increase on total public per capita allocation on health from 10.7 per capita in 2006/07 to 18.8 $ per capita to 2010/11. 138. How could the design of the project been changed given the current knowledge: The design of this project was correct except that the APL was not followed. The WB unfortunately adhered to the traditional mode of running IDA credits. This project did not have a PIU thus it needed more flexibility to manage the project within the government structures. This was a challenge to the project management as required to write multiple reports to meet needs of the WB and for the health basket partners in the SWAp. The WB was demanding special accounts to be opened for every Additional financing provided as an extension of the project. This demand was unnecessary and delayed disbursements of the additional financing part of the project. These demands were not in line with the reforming dynamics not only of health sector but also the government as a whole, which needed to decrease transaction costs. The same WB was advising the government to close accounts to remain only with a few. This again was against the principle of decentralization by devolution (D by D). The communities cannot be empowered by centralizing the funds at higher levels. The resources need to be accessed at the site of implementation. “Putting the financial resources where the mouth is�. 139. Declaration of the Government view on how the project performed during the lifetime given the available evidence of implementation and results: • The Project development objectives of HSDP11 were mostly achieved. • 16 out of 22 agreed indicators for HSDP 11 achieved. • Health System in its wider sense has been strengthened as the project contributed to increased integration of activities t service delivery levels, increased human resource base, 63 strengthened management capacity at different levels of health care through training and recruitment and steps to improve Health Information systems initiated. • Health services are now delivered through a decentralized system. • Improved District level health services. • Improved secondary and tertiary health care delivery systems. • Improved health status outcomes. • Improved access, utilization, quality and financing of health services. 140. Remaining challenges to date include: • Shortage in numbers and skills of health staff particularly at District and lower levels. • Insufficient financial resource given the increasing population and demands. • Slow pace of Hospital Management reforms, the most costly level of service delivery, is still suffering from poor quality control, poor quality of services, while districts have received extensive training in planning and management. • There is a need to intensify supervision, training and motivation, equity deployment of staff, logistics improvement and infrastructure. 141. The implementation of the HSDP11 through its support for SWAp has contributed immensely to the success attained in the delivery on health services in the country. Achievements that we have attained as a Government is a result of many players and partners which we acknowledge. We look forward to further support and collaboration in order to achieve both national and international targets. Long standing partnership with the health sector through existing funding mechanisms, need to be maintained. 142. Lessons learned • The Decentralization by devolution has contributed to increased and improved health sector delivery in Tanzania. • The adoption of the SWAp arrangement with joint plans, actions, harmonized rules and procedures, have broadened the interactions between the MOHSW, MOF and PMO- RALG and the donor community. • Government ownership was critical to successful implementation of the project. 64 Annex 8. Comments of Co-financiers and Other Partners/Stakeholders 143. Thank you for sharing this “IMPLEMENTATION COMPLETION AND RESULTS REPORT� with us. I enjoyed reading the document, I understand better how the WB operates, and why certain issues were so important for the Bank, compared to others (never too late to learn). 144. I can subscribe to most of the achievements you mention in the report. a) Yes the district basket grant has definitely made a serious difference for service delivery at district level as well as for the overall management of resources for health (planning, implementing and reporting). b) The basket has also for sure contributed to the set up and development (with JICA technical support) of the regional management teams, which have the important mandate of quality insurance. Still a lot remains to be done but the RHMTs exist and consolidate. c) But at central level (MoHSW) despite the direct financial support from the PFMRP, and the direct technical support by some partners (Danida, GIZ, SDC...) the overall management of resources does not show drastic improvement. When I compare with 4 years ago, I would even say to the contrary. We still have to struggle to get simple financial and operational information (and when we get them the quality of the information is often questionable), the benchmarks for improved HBF management haven‟t been met, and the elusive ASC meetings do not allow real progress in transparency and accountability. d) It might be worth mentioning in the document (maybe in the context) that there are some very positive developments in the area of accountability, but they are to be found outside of MoHSW => at National Audit Office level (with the CAG producing financial and value for money audits which are increasingly to the point and critical), at CSO level (production of documents analyzing budgetary and operational issues which are shared with the MPs and the media) as well as at parliament level (with the parliamentary committees increasingly active and inquiring). At DP level I‟m not sure that we have been consistent enough in our push for improved accountability. e) Complexity administrative issues and at lack of capacities at the peripheral hindered implementation. The Out Of Pocket appears declining from the NHA of 2008 to be published. 65 Annex 9. List of Supporting Documents 1) Tanzania HAS 2010. 2) Joint External Evaluation of the Health Sector in Tanzania. Final Report. 1999 - 2006 Evaluation Report. 3) Final Audit Report. 2007 -2008. 4) Health Sector Performance Profile Report 2009 Update. July 2008- June 2009. 5) 7th joint Annual Health Sector review; 27th -29th April 2006: Report. 6) TECHNICAL REVIEW 2006. District Health Services Delivery in Tanzania FINAL REPORT. APRIL 2006. 7) Tanzania HIV/AIDS and Malaria Indicator Survey 2007-08. 8) Tanzania Demographic and Health Survey 2010 Preliminary Report National Bureau of Statistics. 9) HSSP III Final document. 10) Memorandum of understanding 2004. 11) National Health-Care Waste Management Plan - Final Report. 12) Country Implementation Completion and Results report 2011. 66 Annex: Other Tables Table 4: Performance Triggers and Status at Close Performance Triggers Means of verification Status 2003 Status 2011 A health sector program integrated GOT budget /MTEF Sector The external resources were “on- Health sector fully integrated and into GOT’S MTEF, with at least Program Documents budget„‟ for there is an increase in both 50% of donor resources for the Quarterly financial FY03. external GBS and SWAp support from 9 partners t 11partners by health sector reflected in the MTEF 2009 District-based health planning and District health plans, As o f July 2003, all districts The quality of CCHP greatly management systems and it s Quarterly financial and physical produce comprehensive plans and improved. Health Centers able to financing through block grants, that progress receive grants against these plans. produce work plans to leverage reports from districts, resources from the district. are linked to outputs /outcomes and performance, operational and tested in at least 30% o f the 114 districts National guidelines for an Essential Audit reports Guidelines for i) The national guidelines for an Further improvements continue in Health package completed, costed; essential health package; Essential Health Package have been development of documents and District management teams trained training developed and costing done. ii) guidelines. National guidelines report Training guidelines have been for essential health care package on it’s use, and quality assurance developed and used in the MPH revised. Update and review of program for basic services in place program in MUCHS and selected earlier generation training functioning Zonal training centers. guidelines. Training programmes District level training is ongoing. A continue with at all levels. review and revision of the planning Provision of health care guides are warranted in view of; a) especially availability of the need for review o f the basket medicines and integrated health restrictions for use o f funds, and b) care at health centre level for inclusion of a minimum set o f improved. Reports and plans at preventive Nutrition interventions. district level more regular and of iii) Quality assurance program: good quality. 67 Access to drugs and training has been strengthened. Further improvements are dependent on stronger/supportive supervision from the Regional level. For HIV/AIDS high level national National HIV/AIDS i) HIV/AIDs Policy in place National multisectoral response bodies (NABA, NAC NACP) Fund established and ii) TACAIDS established to and strategic plan fully functional strengthned multi-sectoral response, operational coordinate a national multisectoral and partners contributing to this strengthened in response and a national national response. staff and fully functional. multisectoral Strategic Framework developed Common disbursement, reporting, Successful implementation of Financial Management and System strengthening in place and monitoring and evaluation systems pilot joint disbursement reporting quarterly financial reporting developed and tested through GOT systems; through the Platinum is in place regularly ongoing Quarterly reports. with quarterly reporting At least 75% o f the Phase I credit Quarterly financial and As o f November 20,2003 94.28% Phase II credit including two disbursed or committed physical reports of the additional financing 99% Credit has been disbursed. disbursed 68 Table 5: Project Risks and Status at Close Risk Risk mitigation measures Risk rating Status at Close 2011 Project Development Objectives Health sector development Strategies Strong M&E, accompanied by targeted LOW Continuous evaluation through strengthned do not lead to anticipated work will be analytical work will be supported to HMIS and regular surveys contributed to supported to continually assess impact, continually and ensure that strategies are generation of information for evidenced Improvements in health outcomes revised accordingly during annual reviews. based policy review at annual review among the poor. maintained the risk at LOW HIV/AIDS morbidity and mortality The Tanzania MAP together with the SUBSTANTI Mitigation of communicable diseases cancels out reductions in transmission MOH HIV/AIDS strategy (including AL through the malaria, TB and HIV and death due to other communicable strategic plan supported by Phase II) programmes strengthned, including the of diseases cancels out reductions in transmission and food fortification program. The overall death due to other Phase 11) are expected HIV policy implementation including for to mitigate the impact of Communicable health workers reduced the risk from diseases HIV/AIDS. However. the risk substantial to MODERATE remains substantial Component results Government or donor commitment Engagement o f a wide range o f LOW Increased donor support over time. By Engagement of a wide range of stakeholders in the to the Program wanes close of project more donors (11)in SWAp stakeholders in the to the Program continual revisiting o f strategies, together than at inception (9) mainlined risk at LOW wanes with the open sharing o f evaluations (whether good or bad) is intended to sustain support. Human resource constraints (vacant Maximize synergies with related MODERATE Increased training programs at all levels end positions, skills mix, mal distribution government strategies ( HSRP, RGW, deliberate policy of recruitment working not adequately addressed by GOT CSRP); engagement by the Bank through a with the civil service human resource sub-regional program of technical division. Zonal centers contributing assistance in HRH; and priority being appropriate skils mix. However, frequent of given by MOH to identifying strategies personnel transfers especially at LGA level suggests that this risk can be managed. maintained the risk at MODERATE Delayed disbursements to the health Closer adherence to the „health planning‟ MODERATE Both GOT and DP closely adhered to health 69 basket process laid down in the Procedure planning and manual for the joint Manuals-for the Joint Disbursement disbursement pattern. As per MOU. System for District Basket Fund and the Government delayed especially in Grant Central Basket Fund. These lay down a funding remained resulting to the health detailed six month process which basket being the principal funding source culminates with BFC approval of the for implementation health activities at health plans at the beginning of the district level. This risk over time reduced to financial year. The “Side Agreement� to LOW the 2003 Annual Review indicates a commitment by partners to reduce these delays. Inadequate procurement capacity of Capacity assessment to verify any MODERATE Strengthned procurement unit at ministry of MOH and LGAs weaknesses and incorporate any action health with resultant regular procurement plan to mitigate these weaknesses, audits as per legal covenants reduced risk to combined with close attention and support LOW from Basket Partners will mitigate risk. Weak governance ( inadequate public Publish information on finances, supplies MODERATE Activity is progressing in some councils on participation, information, at all facilities and Council Health making financial a planning a public. But accountability and transparency) Management Teams (CHMTs), and progress in this area remains low. Increased monitor compliance and accelerate, transparent is councils maintained through establishment o f Council Health Service council financial management committees Boards (CHSB s), HIV/AIDS working through CCHP to define priority actions. Risk in this area reduced to LOW Impact o f HIV/AIDS in the sector HIV/AIDS interventions for health SUBSTATNI Overall HIV intervention measures for the causes such increased workload and workers; AL health worker strengthned. However, personnel loss that staff cannot deliver Strengthening home-based care and the Impact of HIV as well as inadequate HR engagement of other actors through the base still despite increased training puts this MAP should help alleviate the pressure on risk at MODERATE the sector. However, given prevalence, the risk remains substantial. 70 Table 9: Legal Covenants and Stats at Project Close Covenant Status at Close 2011 Disbursement Condition No disbursements will be made into the pooled funds MOU signed before account until a MOU has been entered into among the disbursement was made and Borrower, the Association and the other Donors subsequently reviewed to contributing to the Pooled Funds. accommodate other partners Covenants The government will organize a joint Annual Review no Complied with later than March 31 of Each year to review the progress of implementation as well as a plan and budget for the subsequent year. On a quarterly basis, the government will (a) submit to IDA Complied with and other development partners’ reports on implementation progress and expenditures, and (b) organize basket financing committee meetings for the review and approval of activities to be financed through the basket the subsequent quarter. Annual financial audit reports, carried out by an Complied with independent auditor, will be submitted to IDA and other development partners (in the case of the pooled financing) within six months after each financial year. Annual external procurement audit reports will be Complied with submitted to IDA and other participating Partners by 3 1 December each year. In addition to the formal annual audits, ad-hoc Procurement reviews may be conducted periodically. The Borrower is expected to implement the Project in Complied with accordance with the Project Implementation Plan (as comprised o f the MTEF and the HSSP), the Memorandum of Understanding and the Health Care Waste Management Plan. The government will submit to IDA and other development Complied with partners at least two weeks before each annual joint review: (a) an annual report on implementation progress, expenditures, and results o f any technical reviews; and (b) a draft MTEF for the subsequent year. 71 IBRD 33494R1 TA N Z A N I A SELECTED CITIES AND TOWNS MAIN ROADS PROVINCE CAPITALS RAILROADS NATIONAL CAPITAL PROVINCE BOUNDARIES RIVERS INTERNATIONAL BOUNDARIES 30°E 32°E 34°E 36°E This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any To endorsement or acceptance of such boundaries. 0° Tororo 0° To GAN DA U GAND A Kampala To Kampala Lake To Ka ge r a Victoria Nakuru K E N YA Bukoba Musoma Mara To Nakuru Buoen RWANDA KAGERA MARA 2°S 2°S Lake Mwanza Natron T T To M WA N Z A Simi yu Ka A R U S H A Kilimanjaro ma (5895 m) a a Moshi BURUNDI Arusha To DEM. REP. O F CO NGO OF CONGO Yalova Lake Malindi Mo M S H I N YA N G A Eyasi Lake yow y Kibondo Pa P Shinyanga e Manyara KILIMANJARO n ga p o si g Kahama s 4°S ni ep i Nzega Babati Same St sa Masai KIGOMA PEMBA e Steppe St er NORTH Kasulu MANYARA mb Kigoma Singida Kondoa Kaliua PEMBA Tabora Iwe SINGIDA Wete SOUTH Tanga TA N G A Mkoani ZANZIBAR TA B O R A Lake Ugalla Manyoni NORTH Tanganyika DODOMA ts. Mkokotoni ZANZIBAR M SOUTH & u Zanzibar Koani CENTRAL ur i am Mpanda D O D O M A Ng ZANZIBAR W WEST Morogoro Kibaha R U K WA Dar es Salaam Rung wa Grea MOROGORO MO ROGORO DAR ES SALAAM t Rua ha P WA N I Lake Iringa Sumbawanga Rukwa M B E YA e 8°S ng IRINGA Utete 8°S Ra ro Mpui ya IN DI AN ji e ufi be Mb R Kilom Kilwa Mbeya du Kivinje t an Ma Tunduma Ki pe Njombe O CE AN To Kasama n LINDI ur u mk ge ge be Lindi re 10°S M 10°S Mtwara Ra To n ng Kasama A MB IA Z AM B I A e Songea Masasi To TANZANIA Kasungu MTWARA Lake RUVUMA a Tunduru vum Ru Malawi To Chiúre 12°S To To Lichinga Marrupa MO ZA MBIQ UE MOZAM BI QUE 0 50 100 150 200 Kilometers 32°E 34°E 36°E 0 50 100 150 Miles 40°E NOVEMBER 2007