The Norway-Tanzania Partnership Initiative: A Model for Reducing Child Mortality and Improving Maternal Health

On 29 November 2007, Norway and the United Republic of Tanzania signed a bilateral agreement to support Tanzania's efforts to reduce child mortality and maternal mortality. The modality for support is to channel funds through a common financing basket for the health sector, together with a number of bilateral and multilateral partners, with no earmarking of the Norwegian funds. This marks the end of a one-year planning process, whereby we have attempted to bridge one of the major divides in the current development practices -- namely, between global initiatives mobilizing additional finances for specific themes (in this case, the reduction of child and maternal mortality) and country-led processes of harmonizing and streamlining donor financing -- by incorporating assistance into the development budgets, preferably in the form of general, alternatively sectorial, budget support.

The Norwegian Government, with the strong personal leadership of Prime Minister Jens Stoltenberg, has made reaching the targets set for the Millennium Development Goals -- specifically to reduce child mortality (MDG 4) and improve maternal health (MDG 5) -- a priority for development cooperation. This is expressed through political initiatives, such as the establishment of a network of global leaders, and through earmarking of funds for that purpose in the development cooperation budget, to be used both globally and bilaterally in selected countries. The size of the country, the seriousness of the challenge in terms of the ratios of maternal and child mortality, and the potential for a partnership based on a strong political leadership were all relevant criteria for the selection of Tanzania as a pilot country.

Like many other developing countries, Tanzania has high rates of maternal and child mortality. The figures, from the Demographic and Health Survey of 2004, show a mortality rate of children under five years old at 105 per 1,000 for the country as a whole, with 108 per 1,000 in rural areas and 91 in urban areas. But maternal mortality is much more complicated to assess than child mortality. Multiple sources of information and careful calculation are required, for all estimates are retrospective. It was therefore no surprise that the rates of maternal mortality vary. The 2004 survey calculates the maternal mortality ratio between 1995 and 2004 at 578 maternal deaths per 100,000 live births, which was considered the official ratio. However, the World Health Organization (WHO) has quoted a much higher figure. Its most recent calculation, carried out jointly with the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA) and the World Bank, stands at 950 per 100,000 live births.

There has been some reduction of child mortality in recent years, which can be attributed in large part to preventive efforts. General living conditions, such as nutrition and water supply, have an impact on child survival, as do specific preventive health interventions, such as sleeping in bed nets and being immunized. Maternal and infant mortality, specifically newborn mortality, have not had a similar positive development. In order for these to be reduced, developing countries require well-functioning health services that are accessible to all who need them and are able to respond to acute events. Tanzania therefore has the challenge of increasing and improving skilled attendance at delivery, care of the newborn and swift responses to acute illness of infants. Moreover, unsafe abortion is the second most common cause of maternal deaths, according to official figures. Improved post-abortion care is therefore necessary if the country is going to reach the MDG 5 target of improving maternal health. Following the identification of Tanzania as a potential pilot country, the first step was the consolidation of the partnership process through high-level political commitment and leadership, with the active involvement of the Tanzanian Minister of Health as a key actor. During President Jakaya Kikwete's visit to Norway in February 2007, a joint declaration was signed outlining the intentions of such cooperation. Subsequent meetings between the Norwegian Prime Minister and the Tanzanian President have served to consolidate the high-level political leadership. Their joint membership in the global network of world leaders is a confirmation of this.

The second step -- running concurrently -- has been to identify the modalities of support. Following the Paris Declaration, aid modalities have been changing rapidly in Tanzania. Three elements are particularly important in this context:

  • Strong government leadership, through the preparation of the national development strategy for poverty reduction, called MKUKUTA, and of the joint assistance strategy outlining how Tanzania and its development partners would like the partnership to develop;
  • Improved donor harmonization, through an elaborate structure for coordination among donors and enhanced dialogue between donors and the Government;
  • Changes in aid modalities, comprising increased emphasis on general budget support (GBS), clearly identified by Tanzania as the preferred modality, supplemented by financing baskets in key sectors, including health, and a continuation of project support in areas where donors are not able to change to other modalities. Norway is a strong supporter of this change and is among the donors giving a larger share of its bilateral assistance to Tanzania as GBS (approximately 50 per cent in the current budget year). It was therefore easy for Norway to decide not to operationalize the partnership through a separate Norwegian programme, but to work, as far as possible, through established systems.

As an initial step, Norway considered GBS, but concluded that while this is Tanzania's preferred modality, it would not provide the ideal framework for the dialogue needed or for possible innovations in channelling funds to health institutions. Several donors had already been involved in a long process to establish a health-sector basket to supplement the Government's own financing of that sector. Knowing that reduction in maternal and newborn mortality is very much about strengthening the health system, and seeing that the coordination and dialogue mechanisms created around the sector basket would provide a good framework for collaboration, Norway decided that the health-sector basket would provide the main financing mechanism for its donor support.

Achieving results in the reduction of maternal and infant mortality is not only about money, it is also about ideas, about identifying the key bottlenecks and finding the best ways in dealing with them. For instance, should the focus be primarily on increasing the number of births in health institutions? If so, what would be the most efficient way of achieving this? Or is quality of service in the institutions as important, or more so? And if it is, what can the partnership do to improve quality? There is a need to encourage research, analysis and debate to identify the right actions, and to encourage learning.

Under numerous terms -- results-based financing, pay for performance -- the issue of how aid can be channelled in a way that stimulates change and encourages a focus on achievements is hotly debated. The Norway-Tanzania Partnership Initiative is trying to stimulate a discussion between Tanzania and its development partners on how a part of Norway's support could be used in innovative ways to more directly "reward" good performance. We are not underestimating the challenges involved, but we are also seeing an emerging consensus that this is worth pursuing. One of the important positive aspects of vertical initiatives is their clear demands for documentable results. The existing information-gathering system in the health sector in Tanzania does not provide the documentation needed to determine to what extent the interventions are working. This challenge needs to be approached at two levels: firstly, lay the foundation for an improved overall information system for the sector as a whole. Secondly, spearhead a subset of this system to document results on indicators of particular relevance to MDG 4 and MDG 5. The programme has financed a study containing a proposal for such a system, but to implement it will take time.

Health services in Tanzania are provided by both the Government and faith-based and private institutions. It was agreed that as part of the overall partnership, some funds should be set aside to finance activities in the non-governmental sector. It was also agreed that one of the most important criteria for selecting activities should be complementarity, so that they could prove relevant for the system as a whole, with possibilities for testing out ideas and opportunities for close follow-up on specific issues.

The United Nations is a key partner in the achievement of MDG 4 and MDG 5 -- in Tanzania and worldwide. For Norway, working closely with relevant UN agencies, such as UNFPA, UNICEF and WHO, at the country level would be a natural part of the operationalization of its support. At the same time, Tanzania is one of the pilot countries for the "One UN" programme, which Norway is strongly committed to supporting. The United Nations and Tanzania have agreed that reduction of maternal and newborn mortality should be one of the components in the "One UN" programmes in the country. Norway's core support to "One UN" in Tanzania therefore enables UN agencies to play a key role in this health area.

What we see emerging is a combination of strong political leadership, a clear strategic focus on key determinants of maternal and infant mortality and a renewed focus on innovative ways of working together. This involves an interest in exploring how innovative financing can be used to stimulate improvement and innovation at the local level, a preparedness to combine financing modalities in an optimal way, taking into account both the general trend towards basket financing and budget support, and the need for seed money to stimulate innovation. And all this has to take place within the context of a highly structured and organized interaction between the Government and its development partners.

Norway supports this development process primarily through the GBS and the health-sector basket, by funding research and innovation, and providing core support to the "One UN" and key strategic non-governmental partners. It does so by using all the financing instruments and all the mechanisms available in a flexible, yet integrated, way. And we try to provide ideas!

If we manage to maintain the political momentum created -- such as encouraging more mothers to come to the health clinics, or giving clinics the resources to enable them to provide better care, thereby reducing maternal and child mortality -- and to document the results, we will have contributed to the achievement of MDG 4 and MDG 5. But, most of all, we will have also created a framework that offers a model for other global initiatives on how to become part of the national system for financing development.