Tanzania’s Grand e-health Plan Faces Challenges, Yet Reaches Milestones

Tanzania is unusually ambitious relative to other countries in sub-Saharan Africa and around the globe in having a national government-led digital health strategy, which it launched in 2013. 

The Centers for Disease Control and Prevention-funded Technical Support Services Project (TSSP), led by Management Sciences for Health (MSH), is supporting Tanzania in overhauling its digital health infrastructure, including introducing electronic medical records, hospital facility management software, and a patient ID system. The end goal is to dramatically improve planning and case management for the country’s health services.

We asked TSSP Project Director Dr. Kenneth Lema and Deputy Director Paul Bwathondi for an update on how the country is progressing toward its ambitious digital health overhaul.

How has Tanzania’s ehealth movement been going?

KL: One of the features of this strategy is that it has strong leadership from its own government. But as with any country, that goes side by side with bureaucracy. There is a very clear direction for where we want to go, but lots of stakeholders that must be fully on board to get there. They were ready for change, but were learning to fly on the go. We see government structures being tested. When we started TSSP we had several very active committees; some of them are still there, some have been dissolved. But that’s a very important process for countries to go through—to internalize what it takes to transition to a digital environment.

There are dozens of NGOs involved in the effort. What has MSH’s role been in the program?  

PB: There are both international and local partners who want to play a role, and there are occasionally conflicts of interest. For example, one partner may be supporting a health facility electronic medical record system with a primary focus on improving health care delivery while the other partner is focusing on increasing revenue generation. Partner coordination is a big part of what we do. These conflicts are beneficial, in a way, because they show the extent of the work that needs to be done, and they can be resolved by clearly defining institutional roles and establishing working principles, both of which MSH has supported.

What are some of Tanzania’s challenges that are common to low- and middle-income countries?

PB: A major challenge was the vendor recruitment process. Digital health is a relatively new field of work in development. The ehealth architecture in Tanzania is quite complex, and network skills are important. There are many IT professionals in Tanzania, but that skill set is not really available in the market. MSH has tried to coordinate professionals’ input while developing various information systems, and even went ahead and started an internship program to help build a pool of IT professionals with advanced skills in health systems. 

And once you get people on board, defining and giving people the skills they need is a big challenge. Tanzania also wants to build digital capacity locally, to promote ownership and sustainability, and we’ve been addressing that on all levels, from interns to directors. We have a range of cadres that we have recruited locally.

What challenges are unique to Tanzania?  

PB: When implementing digital solutions, a key success factor is having a strong infrastructure. That includes widely available internet connectivity, sufficient bandwidth, a reliable server hosting environment, and reliable power, especially in rural areas. Digital literacy is another challenge, especially when it comes to decision makers. Electronic systems are relatively new at all levels, particularly in the public sector. Sometimes people at senior levels think it’s just a matter of setting up a computer, without considering that it takes time to learn how to use it. There is also a lot of turnover in the public sector. Some leaders may understand the technology relatively well, but suddenly roles shift and others come to the process who don’t yet understand how things work. Finally, having the financial resources to implement change, including for training, is another factor. Tanzania is among the world’s poorest nations as measured by GDP, but the government is committed to improving health facilities’ infrastructure, and donors have been supportive in building key systems.

What strengths did Tanzania bring to the table? 

KL: Tanzania created a whole new ministry department, Health Information Systems, to focus its interest and commitment. That brings sustainability and ownership of these systems. The department also had the mandate to coordinate and assign roles to external partners and resources, including from PEPFAR, the Global Fund, the Bill & Melinda Gates Foundation, and other donors. 

What are the results to date?

KL: Among the most important is that electronic medical record software is up and running in Dodoma, a big general hospital. The software has been functioning for two years, and the staff are among the biggest champions of that system in Tanzania. It’s now being rolled out in all regional and referral hospitals. 

We also helped develop technical requirements for a national health client registry. That’s now off to a vendor to write the software, which we hope to have within three months. We’ll have a functioning patient registry that provides a unique client identification, which promotes case tracking and management among all of the country’s health facilities. In the US, every person is registered in a system that goes back for hundreds of years. Here, you can be born in a village where there is no birth registry whatsoever. Instead, you have to go by probabilistic ID methods—a mobile number, name, and place of birth. Plus, we have many common names in Tanzania. Even in our working group, there are two Ali Ali’s. There’s a lot to figure out.

How will Tanzania’s progress inspire other countries on the continent?

KL: We plan to showcase our successes. The national referral hospital in Tanzania has a digital facility management system that was introduced some nine years ago. It has undergone continuous improvement, and it’s working very efficiently. It helps in managing patient-level data and makes it easier for clinicians to work. It reduces health care workers’ burden of other tasks, such as developing routing reports manually, and gives them more time to focus on treating patients. I was lucky to be part of the team that developed it. It’s hard to imagine people going back to a paper-based system. It’s a tool they cannot imagine working without. 

A robust electronic system also made handling finances much more efficient. In one month after we installed a pharmacy management module, overall consumption of drugs dropped 80%. There had been pilfering and inappropriate use. The financial savings were tremendous. 

These are things that visitors from other hospitals can easily see: a better working environment; a vital tool for clinicians and other health care workers; a system that helps you manage your resources better, whether it be bed sheets or money. We have proven that a mature electronic system is possible, even in a resource-limited environment like ours. These are lessons we can share.  

Read more about Tanzania’s digital health transformation and the TSSP project here.