Tanzania: Evaluation of the bank assistance to the health sector, 1998-2004

Evaluation Team

This report was prepared by Albert-Enéas Gakusi, Principal Evaluation Officer, Operations Evaluation Department (OPEV) and by Messrs. Thomas O’Brien Kirk and David Royston Moore, external consultants from PEMConsult in Denmark, following their mission to Tanzania in December 2004.

Objective

The objectives of the health sector evaluation are to; a) assess the relevance of funded activities through projects over the years 1989-2004; b) assess the effectiveness of Bank support to the Tanzanian health sector in improving health system delivery and access to health services; and c) identify lessons from experience in order to strengthen Bank’s future policies and procedures and improve quality of Bank operations.The evaluation critically; a) analyses the extent to which the strategies of lending and non-lending activities of the Bank matches the health priorities of the country, and b) assesses the impact of the interventions of the Bank in the health sector showing linkages between the goals/objectives with the outcome indicators targeted by the Bank. Thus, the findings of this evaluation, lessons and recommendations would serve as inputs for the evaluation of the Bank Country Assistance Strategy in Tanzania as well as for future sector evaluation and studies.

Main Lessons

• Investment in health care in rural areas could have very high outcomes even if the investment is limited; an example being the Kitunda dispensary, where the total outpatience attendance increased by 40.7% after the opening of the dispensary.
   
• The use of international consultants, e.g., project director, project manager and project engineer, who are abroad, hinders efficient operations due to communication problems as national counterparts cannot make decisions without the authorization from headquarters and instructions from abroad resulting in impementation delay/s. Where local capacity is weak, any international consultant must be resident in the country during implementation.
   

Main Recommendations

Recommendation(s) to the Beneficiary:

• In order to address the serious staffing problems in the health sector compounded by HIV/AIDs among health staff, the Government should find measures to increase incentives including accommodation and transportation in order to attract and retain adequate health staff. It is also recommended that more hospital managers be trained in order to relieve doctors and other medical staff from administrative and management responsibilities.

• The Government should ensure that the project managers effectively manage and implement projects according to objectives. It should ensure that its investments in the health sector are followed by good maintenance as well as follow-up systems to obtain optimal use. The private sector ought to be involved in improving maintenance.

• Increased use and capacity of local resources should be realistically assessed at the project design stage and adequate capacity development plans integrated in implementing institutions.

Recommendation(s) to the Bank:

• The Bank should join the SWAp in a manner suitable to the Bank modalities. This would reduce the stress on the borrower’s administrative capacity and give the Bank the chance for a larger impact via a more direct participation in the health sector dialogue. Against the context of the increasing number of people living in poverty and increasing or stagnating health problems in rural areas and among the poorest Tanzanians, the Bank’s support in health has been (and is) necessary, but coordination with other development cooperation partners needs to be increased.

• To improve efficiency and impact, the Bank should upgrade its participatory approach in line with its policies, reduce the work load of task managers, as well as increase the quality of its appraisal procedures and the training of staff in implementing agencies. The Bank should appoint a social sector specialist as part of the country office staff

• The Bank should continue to prioritise funds to the level of the dispensary and below in order to improve health service delivery for the poorest areas that suffer highest morbidity and mortality rates. In so doing, the Bank ought to take maximum advantage of a structured participatory approach, thus involving all relevant stakeholders in the project cycle.