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 the 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 for public health facilities. Healthcare quality 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 behaviour.
Well-functioning health systems are critical for delivering quality health services globally. The World Health Organization (WHO) has named three intrinsic goals that are necessary for a health system to perform: improving the health of the population, fairness in financial contribution, and improving the health system’s responsiveness 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 healthcare costs. Addressing this depended critically on strengthening the health service delivery system, including human resources. 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 grassroots level, beginning with community health care, dispensaries, and health centres and continuing through first-level hospitals, regional referral hospitals, and zonal and national hospitals, all providing increasingly sophisticated and well-defined services.
Due to constraints of key health system components, such as human resources, supplies of medicines, and health products, not all primary health services are of sufficient quality. In some geographical regions, populations still live far away from health services. This has mainly 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 an inability at the referral level to provide proper services. Health sector challenges posed by current financing levels and modalities require change to how financial access to health care is organized, more significant 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, increase the number of health facilities, and aim 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 delegating 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, aiming to better address the population’s needs by bridging the gap between health services providers and communities. The current structure of the Tanzanian public health system parallels the administrative division of government authorities in the country. The central authorities control the leading 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 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 steering the health system, together with the Ministry of Health, 1 Ministry of Finance and Planning, and 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 centres) and tertiary-level (district hospitals) structures.
Health facilities are organized in a hierarchical structure 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 using funds for basket funds (through their bank accounts) and 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 to improve 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 to primary care level) and external administrative supervision from council authorities. In addition, specific incentive policies for the retention of health workers have been introduced to improve the 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 centres) and their local government authorities (LGAs) to provide essential health services. Therefore, efforts to achieve significant, sustainable improvements in local health outcomes must ensure that resources (including health staff, drugs and medical supplies, operational expenses, and 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 much on the health sector—close to 10 per cent of its total budgetary resources. Roughly one-third of these resources are channelled to LGAs through sectorial block grants to fund the salaries of local health workers and the operation and maintenance cost of District Hospitals and primary health facilities. On average, LGAs receive around TSH 10,700 per person (USD) in yearly recurrent health grants. In addition, LGAs receive financial resources and in-kind support for providing essential health services from 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, an 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 centres and Dispensaries are the frontline in providing primary therapeutic and preventive health services in Tanzania. They are the primary source of health services for much of the population, particularly in rural areas. Although these facilities run with some degree of autonomy daily, they are supervised by—and fully accountable to—the District Medical Officer (DMO) for all operations.
Sources:
Heal Me | Fais du bénévolat en Tanzanie 2021. (n.d.).
Heal Me | Volunteer in Tanzania 2020. (n.d.).
Going operational with health systems governance …. (n.d.).
Decentralized Local Health Services in Tanzania. (n.d.).
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