FIXING HEALTH SYSTEMS / Executive Summary (2008 update)

December 14, 2010
Sandy Garland


A profound health crisis — major components of which include malaria, HIV/AIDS, tuberculosis, malnutrition, and anemia — has gripped sub-Saharan Africa for many years. Recently, though, the international community has committed more funds to solving a crisis that’s been compounded by poverty and a lack of health care resources.

But will new funding alone produce the desired results? TEHIP was formed to test the hypothesis that health care spending would have a greater impact if directed toward cost-effective interventions aimed at the largest contributors to the local burden of disease.

A unique collaboration between Canada's International Development Research Centre (IDRC) and the Tanzanian Ministry of Health and Social Work, TEHIP provided local health-planning teams in two large Tanzanian districts with tools, strategies, and modest funding increases that have allowed them to target their new resources on the largest contributors to burden of disease and to improve the efficiency of on-the-ground health care delivery.

The resulting large decrease in mortality rates in both districts (particularly amongst children) put Rufiji and Morogoro well on their way to reaching the UN Millennium Development Goal (MDG) of reducing child mortality by two-thirds by 2015.


Information collected through local demographic surveillance systems was used to establish health-intervention priorities in the two districts. TEHIP then developed a series of simple, computer-based tools to help district health planners target their budgets more toward local health priorities. The burden of disease profile tool, for example, presents quickly understood graphic representations of “intervention addressable shares” of burden of disease, allowing planners to allocate their funding in ways that promise significant reductions in mortality. These tools can be adapted for use elsewhere — simply through the provision of local statistical inputs — and have since been adopted by health planners throughout Tanzania.

Using the new tools, the district health management teams reoriented their budgets to place greater emphasis on major causes of mortality such as malaria and a cluster of childhood illnesses. The teams discovered, however, that to effectively address these conditions, it was necessary to increase capacity both at the level of the village clinic and throughout the health system. Subsequently, the teams invested a portion of their modest top-up funds in programs such as new training for clinicians in integrated management of childhood illnesses and in the development of an integrated management cascade, designed to enhance communications and the effectiveness of supervisors, and to increase the efficiency of routine systemic functions, such as the delivery of drugs. This led to greater patient satisfaction and increased attendance at health facilities, and subsequently, to declining mortality rates that were dramatic for children and substantial for adults.


Extensive experience in two large-population districts in Tanzania shows that investing in health systems — to increase the efficiency of health care delivery and to target the most pressing health problems — can lead to impressive results. The fundamental lesson TEHIP draws from this is that international institutions and various levels of government must consider the strengthening of health systems a high priority, alongside the introduction of new therapies, drugs, and vaccines. The development of management tools and strategies also proved to be invaluable aids to the district health teams seeking to improve health services in their areas.

Since TEHIP wound down in the test districts, the principles demonstrated by the project’s success have found new expression both within Tanzania and in other countries. The use of TEHIP tools and strategies has been scaled up to all districts in Tanzania, contributing to greater national progress toward achieving the MDGs. More broadly, new initiatives in Nigeria, Malawi, Kenya, and other African countries (with significant international support) are seeking similar mortality declines by promoting evidence-based health planning and strengthening of local health delivery capacities. In several cases, specific approaches recommended by the TEHIP team have been acted upon regionally and internationally, including the following:

  • Research and development functions should be combined into an integrated program.
  • Significant investment should be made in human resources.
  • Significant investment is needed in critical infrastructure, such as community clinics, vehicles to transport supplies and people, and information and communication technologies.
  • Funding and implementation priorities must be based on local-level, evidence-based plans that consider the local burden of disease. This goal is now being advanced internationally by the Health Metrics Network, housed at the World Health Organization.

Download the PDF: FIXING HEALTH SYSTEMS / Executive Summary (2008 update)