The Tanzanian Ministry of Health
When I was younger, I was involved in a small way with the WHO Global Programme on AIDS and the WHO Health Learning Materials Programme in this country. This brought me into contact with senior bureaucrats in the Ministry. I even partied with the then Principal Secretary on one occasion.
Tanzania was then a socialist one-party state. There are other parties now but none has ever gotten into power. CCM has ruled since independence. Their ministries are centrally run. There is a strong emphasis on manpower-planning and centralised planning. At independence Tanzania had something like four nationals who were doctors. So the need to train health personnel has always been ever-present.
Tanzania is a big country. About the size of France and Germany together. So the problem with centralised decision-making (and a corrupt bureaucracy) could easily be seen by walking out of the MoH, down the street, into a community clinic where the Medical Assistants there (not doctors), did not have basic things like surgical string or plaster-of-paris to treat the people who queued-up outside.
Huge amounts of donor money poured in at the top, but seemed not to have very much effect on the ground, out in the field. Infrastructure also was disastrous so getting supplies out to the regions was also difficult but not impossible. We managed quite successfully using a system of tea-chests and inter-city busses.
This chap pictured here was a colleague. Dr. Amos Mwakilasa. He was Vice Principal at the Centre for Educational Development in Health, Arusha (CEDHA). He went on to become the Assistant Director of the Ministry of Health. Sort-of the 'Sir Humphrey' of the MoH there.
In the last few years the MoH has been going through a strategic planning exercise. The conclusion of which has been to ”get the Ministry out of the provision of health-care nationally!” Astounding. But I can sort-of see the logic. I can’t find a reference to this in English, there are references in a couple of other languages. Here is one in French if you can read that. Amos has been making this argument around the country, in neighbouring countries and to international donors.
The logic goes that they have resource-constraints in all areas. Doctors are fed up with the Ministry and are leaving the country to go and practice in Malawi or somewhere else where they can get on-going in-service training to keep their qualifications current. And to work within a system where the basic necessities of health delivery are available.
Citizens often prefer to visit a traditional healer than go near the hospitals, which they regard as death traps.
AIDS is a national epidemic in the West of the country. In the NorthWest they are overwhelmed by hundreds of thousands of refugees from the strife in Rwanda, Burundi, Zaire, Congo over the last 20 years.
So, it seems to me this is a national confession that “We have failed.” Almost fifty years of Ujamaa (African socialism), centralised planning, manpower development, hasn’t worked.
It is brave to admit such a thing.
The new approach will be to privatise the delivery of health care in the country, in a ‘public-private partnership,’ as the buzzword is. The ministry bureaucrats will no-longer be responsible for healthcare delivery, just ‘governance.’ Liaison, co-ordination, influence peddling…
There is now a bit of a gold-rush as drug companies, health-insurance companies, etc, attempt to stake their claim in this huge country which has a crying need for health services. You can see that there will be huge profits to be made off of all these sick people! A number of Ministry officials may well get quite rich from the process of letting these contracts to suppliers.
A presidential commission headed by Judge Joseph Warioba, has attempted to determine the extent of corruption in the administration and produced a report which placed the Ministry of Health in fourth position in the scale of the most corrupt institutions of Tanzania.
I just feel sorry for all the children who die before the age of five. All the farmers who break their arms and can’t get them set. All the polio and trachoma. All the people in the villages who keel over from undiagnosed bilharzia when the worms drill their livers full of holes. They still have the bubonic plague there in some regions. The people don’t exactly have spare money for healthcare. I guess expensive-but-good services is better than no services. At least the rich will have access now.
Verily, as they say in that country, "Matembo wanaoshindana, manyasi yakunjwe." This means that when elephants contend with one-another, it is the grass that gets trampled. In this context it means that when there are huge changes in ideology and government policy, it is the little people who will end up bearing the brunt of it.
I might be going there next month. I will try and make contact with some people in the know, and see if it is better or worse. Then I will post an update here.