By Goodness Njakoi – Art in Tanzania internship
After past eras of global health focused on the efficiency of interventions, in many low- and middle-income countries (LMICs) policymakers and development partners are gradually directing efforts on improvements in quality of healthcare and equity. The reason for this shift of focus is that the effectiveness and efficiency of investments in health are related to the extent to which healthcare services reach an acceptable level of quality. Moreover, quality of care is a determinant of the use of healthcare services, above all for public health facilities. Quality of healthcare is typically characterized as a three-dimensional construct, the components being resources, processes, and outcomes. Quality of services is closely related to providers’ skills and behavior.
Well-functioning health systems are critical for delivery of quality health services globally. The world health organization (WHO) has named three intrinsic goals that are necessary for a health system to perform namely, improving health of the population, fairness in financial contribution and improving the responsiveness of the health system to the population it serves.
As Tanzania strives to reach middle income status, the health sector has resolved to give more attention to the quality of health services in tandem with the pursuit of universal access. “At the same time, better health for the entire population has been promoted through the adoption of health in all policies.” (“Heal Me | Fais du bénévolat en Tanzanie 2021”) The country has made impressive gains in reducing under-five and infant mortality, through strengthening immunization services and improved preventive services for malaria and other childhood diseases.
The epidemiological transition with non-communicable diseases has shown an upsurge and a subsequent rise in health care costs. Addressing this depended critically on strengthening of the health service delivery system including human resource. The population in Tanzania has increased in the last 10 years. The health system thereby has been adjusting continuously to provide services to an increased number of people. Health services are provided from the grass root level beginning with community health care, dispensaries, and health centers, and continuing through first level hospitals, regional referral hospitals, zonal and national hospitals, all providing increasingly sophisticated and well-defined services.
Due to constraints of key components of the health system like human resources, supplies of medicines and health products, not all primary health services are of sufficient quality. In certain geographical areas, populations still live far away from health services. This has especially been problematic in terms of maternal and newborn care. (“Heal Me | Volunteer in Tanzania 2020”) The referral system does not always function as needed, sometimes due to a lack of adequate transport to the next level of care or due to an inability at the referral level to provide adequate services. Health sector challenges posed by current financing levels and modalities require change to the way financial access to health care is organized, greater efforts on resource mobilization, transparency, and social accountability, as well as more determined measures to strengthen the health system.
despite the Government’s effort to expand geographical access increasing the number of health facilities and aiming at primary healthcare for all, the performance of health providers in rural areas is not yet satisfactory. Health policy reforms in Tanzania touched upon all the points above, including a wave of decentralization by delegation of decisional and managerial responsibilities towards local government authorities. The reform of LGAs in Tanzania strengthened the steering role of councils over the district health systems, with the goal of better addressing the needs of the population by bridging the gap between health services providers and communities. The current structure of the Tanzanian public health system is parallel to the administrative division of government authorities in the country. The central authorities keep control over the main basket fund for health, allocation, and budget for human resources as well as national referral and specialized hospitals. The 30 regions act as intermediary oversight bodies between central and the local authorities, represented by 173 districts. (“Going operational with health systems governance …”) The President’s Office for Regional Administration and Local Government directly oversees and supports the districts in their steering role over the health system, together with Ministry of Health, 1 Ministry of Finance and Planning as well as Regional Authorities. Each district is solely responsible for the management, supervision, and audit of public health facilities within its boundaries, including primary (dispensaries), secondary (health centers) and tertiary level (district hospitals) structures.
Health facilities are organized in a hierarchical structure that is reflected in the referral flows (bottom-up, from primary to secondary or tertiary level structures) and in the cascade supervision arrangements (top-down). Currently, health facilities have autonomy in the use of funds, both for basket fund (through own bank accounts) and for funds generated locally through user fees and Community Health Funds. (“Going operational with health systems governance …”) In the last decade, the Government of Tanzania approved two strategic plans aimed at improving quality of care: the ‘Human Resource for Health and Social Welfare Strategic Plan 2014–2019’ and ‘The Tanzania Quality Improvement Framework in Health Care 2011–2016’. The implementation of bottom-up accountability mechanisms in the healthcare system has been coupled with a cascade supervision system for public health facilities (from tertiary level down to primary care level) as well as external administrative supervision from council authorities. In addition, specific incentive policies for the retention of health workers have been introduced with the aim of improving motivation and satisfaction of healthcare providers.
Over two-thirds of Tanzanians live in rural areas and rely on local health facilities (such as Dispensaries and Health Centers) run by their Local Government Authorities (LGAs) to provide them with basic health services. Therefore, efforts to achieve major, sustainable improvements in local health outcomes will have to ensure that resources (including health staff, drugs and medical supplies, operational expenses, as well as other health-related resources) reach the primary health facilities that form the front-line of public health service delivery in Tanzania.
Quite a bit is known about the composition of public health expenditures in Tanzania. For instance, the Government of Tanzania spends a considerable amount on the health sector—close to 10 percent of its total budgetary resources. Roughly one-third of these resources are channeled to LGAs in the form of sectorial block grants to fund the salaries of local health workers as well as the operation and maintenance cost of District Hospitals and primary health facilities. On average, LGAs receive around TSH 10,700 per person (USD$6) in recurrent health grants each year. In addition, LGAs receive financial resources and in-kind support for the provision of basic health services from a range of various sources, including—among others—the Ministry of Health and Social Welfare; international development partners; user fees; and Tanzania’s National Health Insurance Fund.
Primary Health Facilities (PHFs)
The two types of health facilities closest to the community in Tanzania are Dispensaries (D) and Health Centers (HC). There are currently approximately 3,250 public dispensaries in Tanzania, in comparison to 340 public Health Centers. The formal distinction between Dispensaries and Health Centers is that while Dispensaries exclusively provide out-patient care, a HC should be able to provide around-the-clock care to patients; therefore, any conditions that require in-patient care are referred from dispensaries to the nearest Health Center. “However, the distinction is less clear as many Dispensaries have been upgraded to provide child and maternal health services.” (“Decentralized Local Health Services in Tanzania”) Health centers and Dispensaries are the frontline in providing primary therapeutic and preventive health services in Tanzania and are the main source of health services for much of the population, particularly in rural areas. Although these facilities run with some degree of autonomy on a day-to-day basis, they are supervised by—and fully accountable to—the District Medical Officer (DMO) for all aspects of their operations.
Heal Me | Fais du bénévolat en Tanzanie 2021. (n.d.).
Heal Me | Volunteer in Tanzania 2020. (n.d.).