Strengthening district health systems.

It is increasingly recognized that stronger health systems are needed to deliver health care interventions at the scale necessary to achieve and sustain healthrelated Millennium Development Goals (MDGs), especially in Africa (1, 2). This is evident in the growing willingness of two of the largest global health initiatives, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Global Alliance for Vaccines and Immunization, to allow increasing shares of their contributions to be used for investments in health systems strengthening. This is welcome news, especially for the peripheral front lines of delivery systems. How can we strengthen health systems to respond to these new resources? As there are so many needs and entry points, it is tempting to bypass the system with vertical approaches, but the space for such approaches is increasingly crowded as they depend on and compete for the same health workers and management capacities. For this reason, the recent experience of strengthening subnational health systems in the United Republic of Tanzania (3) deserves our attention. A demonstration project was started in 1997 in two large rural districts (the Tanzania Essential Health Interventions Project, TEHIP).a The project explored how to use limited resources efficiently in view of forthcoming policies on sector-wide approaches (SWAps) to decentralized district funding. Within five years, these districts had improved the mix and quality of primary care services, increased the coverage and use of these services, and reduced infant and under-five mortality by over 40%. Significantly, this was accomplished by using a donor-provided extrabudgetary increment of about US$ 1 per capita per year and a tool kit of about ten simple tools and strategies aimed at various elements of the health system (4). The stewardship function was met by relaxing the normal constraints on the use of basket funding, thus permitting district health management teams to invest in strengthening their own practical