United Republic of Tanzania

Between 2010 and 2015, Tanzania saw notable improvements in life expectancy (from 61.6 to 64.9 years), infant mortality rate (from 51 to 43 per 1,000 live births), under-five mortality rate (from 81 to 67 per 1,000 live births), and under-five stunting prevalence (from 42 to 34.4 percent). However, during this period the country’s maternal mortality rate increased from 454 to 556, and its total fertility rate remained stubbornly high at 5.2 (as of 2015). The increase in maternal mortality elevated maternal health to a national priority. To address this and other lingering challenges in RMNCAH-N, in 2015 Tanzania began implementing its RMNCAH-N investment case, known as One Plan II.

One Plan II prioritizes pivotal interventions to accelerate RMNCAH-N improvements focused on increased quality, access, and use of RMNCAH-N services. These include antenatal care, use of skilled birth attendants, and a package known as Basic Emergency Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC).


Estimated Contributions from Major Financiers as a Percent of One Plan II Budget Need 2017

Plan Development, Partnerships, and Funding

The plan was developed in a consultative process through Tanzania’s RMNCH Technical Working Group. Key financiers support different aspects of the government’s strategy to address RMNCAH-N challenges and improve financial transparency. The GFF played a critical role in mobilizing financiers to pool funding in support of the World Bank Primary Healthcare for Results initiative. The financiers of this initiative are the GFF Trust Fund, Power of Nutrition, USAID, and the World Bank. The Health Basket Fund pools support from the governments of Canada, Denmark, Ireland, and Switzerland, as well as UNFPA, UNICEF, and the World Bank. A recent resource mapping of funds provided by these major financiers shows that the plan is 67 percent funded (see Figure 6).

Several priority areas of One Plan II remain underfunded. These include strengthening service delivery for maternal complications and newborn care, adolescent health, gender-based violence, reproductive cancers, and community health. Despite major strides in partner alignment and resource transparency, further work is needed to align all partners around One Plan II and further share information on financial commitments.

Moving Toward Universal Health Coverage and Equitable Access

To facilitate long-term sustainability of health gains, the Government of Tanzania is taking critical steps to increase the resources for and sustainability of health financing. The government is currently developing a five-year Health Financing Strategy to move toward universal health coverage, a critical step to ensure financial protections for the poor and reduce catastrophic health expenditures. The GFF supports the government in this effort with technical assistance, capacity development, and analytics to finalize the Health Financing Strategy and promote a related single national health insurance bill.

The government is also implementing key initiatives to improve equity in access to health services. Improved access to services for the poor is essential for Tanzania to ensure RMNCAH-N achievements are reached and equitable.

Early progress noted

In regions implementing results-based financing, the number of individuals identified by the Tanzania Social Action Fund as being below the poverty line who receive outpatient care increased considerably between mid-2016 and the end of 2017 (see Figure 7).


Percent of Low-Income Individuals Identified by Tanzania Social Action Fund Receiving Outpatient Care by Province, Quantity Data April 2016-Dec 2017

A Results Focus

One Plan II implementation has a strong results focus. A district-level scorecard is currently used at all levels (national, regional, and district) to monitor One Plan II results and allow continuous programmatic improvements—all based on data.

Early progress noted

A recent review of One Plan II results shows improvements between 2014 and 2017 in key service delivery interventions to improve RMNCAH-N, including increases in institutional deliveries, the percentage of pregnant women receiving at least four antenatal care visits (ANC4), the percentage of facilities receiving at least three stars (out of five) in the star-rating quality assessment, and coverage of intermittent preventative treatment (IPT2) for malaria during antenatal care visits (Figure 8). Although it is too early to tell if maternal mortality will be impacted by these interventions, improvements in their coverage should result in reductions in the maternal mortality ratio. In addition, the continuous availability of 10 tracer medications has undergone notable improvement: there has been a doubling in the number of facilities that have the entire tracer drug package (from 31 percent in 2014-15 to 60 percent in 2016-17). These increases represent gradual, substantive quality and coverage improvements.


Nationwide Coverage of Key District-Level Scorecard Indicators (DHIS2), 2014 -2017

Areas where progress is lagging

Along with the above-noted improvements, however, iron supplementation coverage declined during this period. Analysis into the reasons behind this decline found gaps in the availability of iron tablets. In addition, ANC4 coverage improvements have been more modest than hoped. The 2014 baseline for ANC4 coverage was low at 35.1 percent and increased only to 46 percent by 2017.

Corrective Actions

These results have spurred the government to conduct in-depth analysis into the underlying reasons for lagging ANC4 coverage. The analysis revealed substantial geographic disparities between regions, with coverage ranging from a low of 34 percent to a high of 69 percent (Figure 9). Further exploration into the root causes of low ANC4 coverage has found that it is influenced by women’s reluctance to disclose that they are pregnant during the early stages, health workers encouraging patients to seek initial antenatal care appointments only after 12 weeks of pregnancy, and low availability of pregnancy tests to confirm early pregnancy. Based on this in-depth data and qualitative analysis, the government is taking action to improve ANC4 coverage, including improving the RMNCAH-N component of community health workers’ training, conducting refresher trainings on antenatal care guidelines for health workers, strengthening the antenatal care component of the facility supervision checklist, and improving data use at the facility level.


Antenatal Care Coverage by Region, 2017

Improving Service Quality

To ensure improved RMNCAH-N outcomes and service uptake, strengthened service quality is a priority in One Plan II. Tanzania’s star rating system, evaluated by a quality assessment tool administered by the Ministry of Health’s quality unit, ranks facility quality on a scale from zero to five stars. The system acts both as a measure of quality and a way of creating improved, publicly available, information on facility quality.

Early progress noted

The 2015-16 baseline star rating assessment found that only 1 percent of facilities received three or more stars. Initial results from a 2017 reassessment found that this number jumped to 22 percent of facilities receiving three or more stars. Although there are marked differences in the level of improvements between regions, all regions reassessed to date have seen some improvements (Figure 10). These quality improvements are expected to have substantial impacts on RMNCAH-N outcomes. Review of the star rating tool and other quality measures found that many of the current quality achievements are based on improvements in structural quality, such as facility buildings and equipment availability. Currently, work is underway to update the star rating tool and other quality measures to more thoroughly assess the quality of health service delivery.

To further improve results tracking, the Office of the Vice President of Tanzania is launching an RMNCAH-N scorecard, which will incorporate the district scorecard as well as other key aspects of One Plan II’s results framework. This scorecard will help the RMNCH Technical Working Group and the government continuously monitor all areas of One Plan II implementation and make programmatic adjustments based on results. In addition, the scorecard will be used to hold regional level authorities accountable for RMNCAH-N results, a critical step towards institutionalizing RMNCAH-N as a national priority.

We are well taken care of and the nurses are always welcoming.

– Marie Kumba, Holy Spirit Health Center. She came to the center for all of her prenatal consultations, where she also received a bed net provided by Sanru, an NGO that delivers Global Fund bed nets.

Percentage of Facilities Receiving High Ratings (three or more stars) in Initial Reassessed Regions, 2015 vs. 2017

Steps for Continued Programmatic Improvement

In the process of reviewing RMNCAH-N results, the government found remaining challenges with data use at the facility, district, and regional levels. To further improve data use, the GFF Trust Fund plans to support improved data for decision making, including analysis of data quality bottlenecks, development of a data visualization platform, strengthening the RMNCH Technical Working Group, and improved resource tracking.

As a GFF front-runner country, Tanzania was one of the first countries to develop a GFF investment case. To maximize RMNCAH-N improvements, the country is embarking on a midterm review of One Plan II which will include a review of implementation progress; comprehensive resource mapping; adjustment and reprioritization of strategies based on lessons learned, available resources and current RMNCAH-N evidence; and updates to the plan’s results framework and baseline data.

The government also plans on requesting additional financing from the World Bank to improve adolescent health services, expand civil registration and vital statistics, further improve service quality, and take additional steps to reduce the country’s high maternal mortality rate. These next steps, identified through review of One Plan II results, will build on the investment case’s initial progress to further catalyze RMNCAH-N improvements.

“When mothers have to go into delivery, the Community Health Workers escort them to the hospital. This is the area where they have helped us a lot.”

– Justing Mayumbavv, registered nurse, Mhandu Dispensary, Shinyanga District

Democratic Republic of the Congo

In the Democratic Republic of Congo (DRC), the GFF was launched in April 2015. The government put in place a GFF platform that brought together the key government health stakeholders, other line ministries, civil society representatives, and development partners. The GFF platform took the lead in developing the country’s RMNCAH-N investment case, which prioritizes the interventions laid out in the National Strategic Development Plan 2016-2020. The Ministry of Health, with representatives from civil society organizations, focused on defining RMNCAH priorities; UNICEF conducted a health system bottleneck analysis; WHO provided support in costing the investment case; and the GFF Secretariat helped with the resource mapping exercise with the support of the government and several donors.


The Republic of Cameroon

Despite its lower-middle-income status, Cameroon was recently ranked 153rd out of the 188 countries tracked in the Human Development Index (HDI 2014) and, indeed, it is one of a group of countries whose HDI scores have declined in the past two decades. Contributing to this HDI deterioration is slow progress on key health outcomes.



Nigeria has always been committed to the principles of universal health coverage and has adopted policy documents and legislation to that effect. However, indicators of Nigeria’s health outcomes and actual coverage of basic health services show under performance, both in absolute terms and relative to other countries at similar levels of economic development. Key drivers of underperformance include a health system unable to ensure universal coverage of primary health care services and weak accountability for results. The health sector has long been underfunded, and its structural and institutional frameworks have placed concurrent responsibilities on all three tiers of government (federal, state, and local) without any mechanism for intergovernmental accountability.