Decentralisation and gender in Tanzania - using maternal health as an entry point.

Tanzania initiated the Local Government Reform Programme in 1996. The objective of the reform is decentralisation by devolution, and to strengthen local authorities' ability to deliver quality and accessible services in cooperation with local communities, civil society organisations, the private sector, and other development actors.

This project, which started in February 2007, is organised by the President's Office for Regional and Local Authorities (PMO-RALG), with support from Norwegian and Tanzanian consultants. The project has been conducted in three phases. In the first phase, the research team studied various forms of coordination and cooperation in four districts, using maternal health as an entry point and example. Four districts with relatively low maternal mortality rates were selected: Ileje, Misungwi, Serengeti, and Moshi rural. The objective of the study was to identify if, and in what ways, these districts perform better than others when it comes to cooperation on maternal health, and to identify best practices and disseminate the practices to other districts.

In the case of Moshi rural, the low MMR is first of all due to the high level of education of the inhabitants, the positive economic situation, women's income, and a large number of health facilities (partly established by missions, partly by self-help activities and wealthy individuals). These are all factors that are hard to replicate in districts that have less favourable socio-economic backgrounds.

Ileje, Misungwi and Serengeti, on the other hand, are more interesting in terms of replication and learning. The three districts are all relatively poor, and the low maternal mortality rates are the result of specific area based donor funded projects and local initiatives targeting maternal health (as well, in the case of Ileje and Serengeti, mission hospitals).

All the projects focusing on maternal health have similar characteristics:

• Vertical cooperation between health facilities and staff: regional, district and village
• Horizontal cooperation between health facilities, government and private
• Focus on voluntary village health workers and village health committees
• Focus on increasing delivery at health facilities and improvement of health facilities
• Mobile clinics and outreach units to isolated areas as well as improved means of transport and communication
• Committed and serious key staff and improvement of health workers' attitude and language
• Women's economic empowerment was a key factor in all the projects; one of the projects included savings groups for delivery and transport expenses. Two of the district projects included a male involvement, i.e in the savings groups and in the transport on stretchers when pregnant women needed to go to health facilities for delivery.

In the second and third phases of the project, PMO-RALG and the consultants have arranged workshops in Chunya (Mbeya Region), and Mwanza City (Mwanza Region) where five to seven representatives from three to four districts have met to share best practicies and experiences when it comes to coordination and cooperation to improve maternal health. It has been revealed that while some districts have close cooperation with civil society organisations and invite them to council meetings and include their work in their district health plans, this does not happen in all districts. A final workshop will be arranged in April 2008 - for districts in Rukwa region.