Joint External Evaluation of the Health Sector in Tanzania: Draft ...

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• A national referral hospital in Mwanza; • Regional Secretaries for each of the six councils; • Regional Medical Officers (RMO) and the Regional Health Management Teams (RHMT) in six regions associated with the district case studies; • Six Regional Hospitals; and, • Three Zonal Medical Stores and five Zonal Training Centres (ZTC). At district level: • Six District Executive Directors (DED) as representatives of local government; • Council Health Services Board (CHSB) Members for five of the six districts; • Current or acting District Medical Officer (DMO) and the Council Health Management Team (CHMT) for each of the six district case studies; • Hospital Management Teams (HMT) for four District Hospitals (two councils did not have a District Hospital but relied on the Regional Hospital); • Seven other hospitals at hospital level operated by FBOs and the private sector; • Fifteen Health Centres and 21 Dispensaries; and, • Focus group discussions to assess changes in health services with 21 different groups (nineteen of which were separate male and female groups) encompassing 293 individuals chosen from the communities in each of the six council areas. In addition the evaluation conducted a document review of all available and completed CCHPs prepared by the six councils as well as facilities level data at regional and district hospitals. Review of Health Outcomes The evaluation has relied on existing primary and secondary data sources to assess changes in health outcomes during the evaluation period, especially as they relate to the achievement of goals and targets in health as set out in the National Strategy for Growth and Reduction of Poverty (MKUKUTA) and the MDGs. Reviewing Financial Flows The evaluation undertook a review of available sources of financial information on the health sector during the evaluation period. Sources included: • Public Expenditure Reviews (PER) for Health in Tanzania; • GoT Budget Execution Reports; • The Ministry of Finance Integrated Financial Management System; • Votes and sub-votes as reported in the Budget Estimates; • Medium Term Expenditure Frameworks; • The Tanzania PER Multi-Sectoral Review: HIV-AIDS; and, • Data provided by specific DPs and the Ministry of Finance (MOF). In addition, this methodology encompassed interviews with officials of MOHSW and MOF and selected DPs in Dar es Salaam. It also included a set of finance and financial systems focussed interviews with representatives of Kigoma/Ujiji Municipal and Rural Councils and the Kigoma Regional Hospital in order to better map the operations of 20
udgeting and expenditures at council level, including transfers from the Central Government and to gain a better understanding of the management of cost-sharing funds. Assessing Development Partnerships In addition to touching upon cooperation modalities and different dimensions of harmonisation, alignment and dialogue in relevant interviews, and searching for information on this in the document reviews, a number of separate efforts were pursued in order to respond to the evaluation issues in this area. This included participant observation by members of the evaluation team in the December 2006 meeting of the Development Partner Group Health (DPG-Health) and the January 2007 Health Sector Wide Approach (SWAP) Committee Meeting. The reports and minutes from all the JAHSRs (main reviews and technical reviews) and minutes of the Health SWAP Committee and Basket Funding Committee (BFC) were compiled and systematically screened. Interviews were conducted with representatives of the MOHSW to specifically address the questions of development partnerships. Triangulation and Cross Validation Finally, the methodological approach of the evaluation included a systematic effort to triangulate data from document reviews, key informant interviews, direct observation of facilities, and focus group discussions in order to strengthen the validity of findings and conclusions. 1.3 Challenges and Limitations The evaluation faced a number of important methodological challenges. The major challenges and the strategies developed to deal with them included: Integrating District Self Assessments and Case Studies A methodological feature established clearly in the TOR was a requirement that the evaluation should make use, to the extent possible and justified, of the district self assessments as well as the district level studies carried out by the team of external evaluators (district case studies). Indeed, this was essential if the evaluation was to achieve coverage of more than ten % of the districts in mainland Tanzania as also required by the TOR. There were important methodological differences between the district self-assessments and the case studies carried out by the external evaluation consultants. The former were focused on the perceptions of staff and system users at a single point in time as selfreported through focus group discussions. The case studies focused on changes over time as distinct from a situation or perceptions analysis, and included document reviews and site observations as a check on the perceptions of managers and health facilities personnel. This challenge was addressed through an analysis of the individual reports of the sixteen district self-assessments. First, each of the sixteen reports was summarized by issues area and by reported findings on positive achievements, constraints and challenges and recommended actions. These were then coded to display each finding and associated district. This was the basis for assessing the extent of alignment in both positive and negative evaluation findings between the district self-assessments and district case studies. Because 21
Page 1 and 2: Joint External Evaluation of the He
Page 3 and 4: 9 Health Care Financing............
Page 5 and 6: Abbreviations ACT Artemisinin-based
Page 7 and 8: MTEF Medium Term Expenditure Framew
Page 9 and 10: Executive Summary During the 1990s,
Page 11 and 12: Achievements Under Health Sector St
Page 13 and 14: their overall spending has risen si
Page 15 and 16: National ownership has been strengt
Page 17 and 18: 1 Evaluation Approach and Methodolo
Page 19: The evaluation developed a document
Page 23 and 24: 1.4 The Evaluation Team A team of e
Page 25 and 26: • Weak Health Management Informat
Page 27 and 28: 3.2 Relevance of External Support E
Page 29 and 30: However, the decentralisation proce
Page 31 and 32: Finally in regard to CHSBs, members
Page 33 and 34: The process of preparing the annual
Page 35 and 36: feature more largely in health plan
Page 37 and 38: 5 Changing Roles of the Central Min
Page 39 and 40: cooperation should work at differen
Page 41 and 42: 3. health inspectorate (at present
Page 43 and 44: The HSSP2 did include most of the p
Page 45 and 46: Regional Hospital, Mwanza) of drugs
Page 47 and 48: 7 Central Support Systems Conclusio
Page 49 and 50: new public facilities very near tho
Page 51 and 52: Vertical Programmes The inefficienc
Page 53 and 54: udget, or assist HFs in using cost-
Page 55 and 56: MSD’s Monopoly and Alternative So
Page 57 and 58: topics. The limitation of these sou
Page 59 and 60: HRH management capacities, increase
Page 61 and 62: less likely to migrate (page 48). O
Page 63 and 64: The district case studies were not
Page 65 and 66: individual targets, there is no obj
Page 67 and 68: Table 2: Overview of Main Sources o
Page 69 and 70: during the evaluation period, most
Page 71 and 72:
sustainable in the medium term give
Page 73 and 74:
9.4 Budget Performance Overview A k
Page 75 and 76:
of cost sharing and risk pooling me
Page 77 and 78:
therefore important that an exempti
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10 Public Private Partnership Concl
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The Technical Review presented the
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The district self-assessments and d
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11.1 Achievements in Extending HIV/
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• Post-Exposure Prophylaxis (PEP)
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11.3 The Challenges of Integrating
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12 Service Quality, Access and Equi
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services 99 . Of the groups partici
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Equity Issues and MOHSW The issue o
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Table 6: Progress Against Targets I
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With regard to tuberculosis, MOHSW
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14 Development Partnership Conclusi
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More recently, the MOHSW has been a
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The DPG Health meetings have addres
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considerable resources have been ch
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informants felt that the presence o
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still only part of the picture and
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15 Main Evaluation Conclusions Chap
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egional offices should be establish
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inspectorate, regulation of the pri
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process of drugs procurement and su
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Recruitment and Deployment 77. Coun
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108. Depending on the activity leve
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Annex 1 Evaluation Terms of Referen
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personnel from 50% to 80%, and vari
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the involvement and thus the owners
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4.3 Intended Users/Audience of the
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esults of existing quantitative sur
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• Assess the efficiency of inputs
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o Interrelation in terms of availab
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o Ability of the target population
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o Adequacy of objectives and strate
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Abdallah, S., Mwihumbo, T., Ndangal
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Government of Tanzanina Terms of Re
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Annex 3 Documents Reviewed 147
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Garrett, L (2007) The Challenge of
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Government of Tanzania (2004) Tanza
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Government of Tanzania (April 2003)
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Humba, Emmanuel (2005) Social Healt
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WHO (2001) Macroeconomics and Healt
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MOHSW Harun Kasale, lead consultant
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Association of Private Health Facil
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Annex 5 Financial Charts and Models
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Chart 5: HIV/AIDS Financing Aid Not
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Financial Flow Models Flow of Funds
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Name District: ………………
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