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

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noted weaknesses in supervision. One achievement has been to extend supervision beyond the public system to include all FBO and private HFs. However, the district case studies note that supervision tends to focus on administrative and data management matters (HMIS) rather than improving clinical practice. 4.4 Community Participation The most important way in which community members are involved in the planning and management of council health services is through their participation in PHF committees. This seems to work relatively well because the HF is close to the members, committee members are regular users, and their contributions have reportedly resulted in visible changes/improvements. In contrast, participation by community members in planning and monitoring at the wider council level is minimal. In particular, the CCHP process in the six case study districts saw little involvement from community members. Nyaywa and Petersen’s assessment of CCHPs for 2006/07 from 60 districts found that only twelve % had participation from FBO/VA/CSO/private sector agencies and only three % had representation from the wider community. Representatives of these organisations interviewed during the district case studies often, but certainly not always, rated their participation as minimal. There are a number of possible causes for this lack of community participation in health planning. One may be the time constraints faced by CHMTs and the tendency to focus on the CCHP as purely a budgeting rather than a planning exercise. Another possible explanation could be the scarcity of competent community members to serve on the CHSB or take part in the CCHP exercise. Ultimately, of course, the lack of community participation in preparing CCHPs may reflect an ongoing and in-built tendency for the managers involved to see health sector planning as their domain of expertise, at least at the overall council or district level. It may also be due to a genuine lack of interest on the part of community members at any level above their own health facility, in which case it may not be possible make CCHP development truly participatory. It was clear in the case study councils that, once the CCHPs are produced, they are not distributed beyond the members of the Planning Team, PMO-RALG and MOHSW. The evaluation did not meet anyone who had a copy of the CCHP or even extracts of the relevant pages of this. In fact, most had never seen a CCHP for their council. 4.5 Intersectoral Collaboration The importance for health of close collaboration with other sectors is emphasised in the POW (but not in the HSSP2). Nyaywa and Petersen (2007) found in their assessment that water and sanitation was the number ten priority listed in CCHPs, so there is some evidence that concerns outside the traditional health sector are reflected there. On the other hand, the district case studies did not find significant evidence of multisectoral activities at council level. TACAIDS, however, is one example of a multisectoral programme working at regional and council level. Devolution should in theory facilitate cross-sectoral cooperation at council level. Given the fact that clean water and sanitation, hygiene measures, nutritious food and basic education all substantially contribute to health, active cooperation across sectors could be expected to 34
feature more largely in health plans. Village and ward level health committees could play an important role in building linkages to other sectors in the development of CCHPs. 4.6 Essential Clinical and Public Health Packages In 1999/2000 Tanzania defined a National Essential Health Interventions Package (EHIP) to be delivered in the districts 21 . To be included in the package interventions should: address major health problems, have significant impact on health status, be cost-effective, improve equity, respond to demand and have a ‘public good’ character. The EHIP has five major components: reproductive and child health, communicable diseases, non- communicable diseases, common diseases and health promotion. Each category contains a number of disease groups, specific diseases and/or intervention groups. While this list was already quite long compared to that of other countries (including e.g. diabetes, mental disorders and neoplasm), in the subsequent National Health Policy more items were added. Almost every intervention regularly provided at the district level is considered a priority. The list is therefore more useful as a classic example of consensus policy than as an effort at painful, yet realistic priority setting. Moreover, the package was never properly costed and it is very doubtful that the limited resource envelope available to councils is sufficient to fund delivery of the package. Nevertheless, a main objective of the POW was to deliver a quality EHIP. The HSSP2 mentions that priorities in the EHIP should be better defined, but document reviews and interviews indicate that, outside of the TEHIP pilot project in two districts, the topic has not received as much attention over the evaluation period as could be expected. The TEHIP tools, now included in the new PlanRep2 software, to establish a council specific EHIP, could be effectively used to establish a limited number of high priority interventions, which could then possibly be included in the CHF package. 4.7 Referral Although ten out of sixteen district self-assessments conclude that the referral system has improved at least somewhat, the six district case studies strongly indicate that referrals are still not functioning properly (as in many other developing countries). A number of reasons have been mentioned for this: • There is no clear distinction between levels of care: some regional hospitals function as district hospitals (but at a higher cost), some FBO district hospitals offer higher level services than the closest referral hospital, and some HCs are not very different from dispensaries 22 ; • People go to the nearest HF for all their health needs, regardless of the level of the HF, saving time and transport costs; • People have ample opportunity to bypass, as in general there is no bypass fee; • Where there is a bypass fee, people are willing to pay it in order to receive higher quality care (as reported by Bugando Medical Center (BMC); • Dispensaries report that they often refer patients straight to the hospital, rather than first to the HC, in order to prevent them having to be referred by HC to the hospital all the same. 21 National package of essential health interventions in Tanzania. MoH, January 2000. 22 The fact that levels of care available in one type of facility often cannot be distinguished from those in a facility of a lower level, was also already mentioned in the POW 1999 as a problem with referral. 35
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 and 20: The evaluation developed a document
Page 21 and 22: udgeting and expenditures at counci
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: The process of preparing the annual
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
Page 79 and 80: 10 Public Private Partnership Concl
Page 81 and 82: The Technical Review presented the
Page 83 and 84: 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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