Poor People’s Experiences of Health Services in Tanzania

\ud Tanzania faces serious challenges to improving the health and well-being of its people. The Ministry of Health and its partners in government, the donor community and civil society have responded with concerted action, in many cases achieving significant gains. Services for prevention of mother-to child transmission of HIV are being expanded, a new protocol for malaria treatment is being implemented and evaluated, hundreds of service providers are now trained in life-saving skills for childbirth, and all districts have been oriented to the programme of integrated management of childhood illnesses (IMCI). These are but a few of the successes in recent years (MoH 2004a). These achievements are particularly notable given serious funding limitations in the health sector. The allocation to health has increased only slowly over recent years, from 7.5 percent in fiscal year (FY) 2000 to 8.7 percent in FY03, which is low in relation to projections in the Poverty Reduction Strategy (PRS) and to the Abuja commitment of 15 percent. Again, despite the PRS commitments, the absolute budgetary increase year-to-year has declined from a high of 41.12 percent in FY02 down to a 5.68 percent increase in FY04 (MoH 2004b). The FY05 budget ceilings indicate that the health sector will actually have fewer resources in real terms than in FY04. However, the low level of funding does not categorically preclude improvement of health services and ultimately health outcomes. “Differentiated” allocation of government funds, including in the health sector, can better prioritise the needs of the poor. The continuing disparities in health outcomes between the poorest and the richest Tanzanians and those in rural versus urban areas need to be addressed, along with the barriers to service experienced by the poor due to distance, formal and informal health charges, and other obstacles reported in this review (R&AWG 2003). The new resource allocation formula that utilizes equity criteria to distribute funds across districts, and the increasing proportion of funds for preventive services, are both positive developments in reaching the poor. Nonetheless, additional actions are needed to mobilize meaningful change for Tanzanians living in poverty. To move beyond policies and guidelines. To make tough decisions about how to bring the poor into the mainstream of health services, to focus differentiated attention to their well-being, and to bring critical human and financial resources to bear in one of the most crucial areas of Tanzania’s development: the health of its people. This literature review examines key findings on poor people’s experiences of health services and includes a particular focus on the barriers to access among the very poor due to cost sharing, an issue of special interest in the current era of “pro-poor” development. The review highlights seven key issues for reflection – and action: Access: Health services are often not accessed by the very poor, and by women in particular. Key obstacles are health care charges, long distances to facilities, inadequate and unaffordable transport systems, poor quality of care, and poor governance and accountability mechanisms. There have been improvements in availability of drugs which is a positive development, but some continuing deficiencies and particularly the cost of drugs still make them unavailable to many poor people. The shortage of skilled providers, while a serious concern to all actors in the sector including government, continues to persist. Discrimination against clients who are not able to pay and poor referral systems all result in low quality of care. Health care charges: Revenue generated by cost sharing has not necessarily impacted positively on quality of health care. User fees are not the only charges; other costs include transport costs, other “unofficial” costs including bribes, payments for drugs and supplies, and time spent away from productive activities which is particularly critical for people living in poverty. Health care charges have placed an impossible financial burden on the poorest households; many fail to access primary care when they need it most and many more fail to obtain the necessary referral for more skilled care. People do not always know what they are supposed to pay, and which payment demands are legitimate or illegitimate. Official charges are not necessarily affordable. “Unofficial” charges are still in place, and exemption and waivers have not been effectively implemented. The quality of care in public facilities has not necessarily improved even with the additional funds generated from user fees. The Community Health Fund may have improved the quality and range of services in those places where the CHF is in place. However, the scheme is not necessarily benefiting the very poor in a more equitable way. Many report they are not able to afford the joining fees and therefore pay for treatment on a case-by-case basis, which can ultimately be more expensive. more expensive. Participation and decision-making: Community participation is very limited in regards to determining health care priorities, deciding where funds should be allocated, and monitoring expenditures. This is a problem across priority sectors, not only in health. It is due in part to a general lack of knowledge about rights and recent reforms. More importantly though, reliable mechanisms are not in place for discussing issues of concern at the village level and then raising these concerns to the district level for action. Governance and accountability: Health consumers express dissatisfaction with critical governance issues such as abuses of power, financial mismanagement and corruption. While there exist some cases of health users and authorities working together, systems are generally not in place to ensure that services respond to the priority needs of beneficiaries. Adequate management systems have not been instituted to ensure appropriate collection of fees and allocation of these locally-generated resources. Government has recently begun to publish information on priority sector allocations for each district; this is an important development in enabling people to monitor public funds earmarked for critical services. Because this information is not disaggregated below the district level, however, it is not possible to monitor expenditures at the village or facility level. Exemptions and waivers: Exemptions, and in particular waivers, are not systematically implemented and are not effective as a means of protecting vulnerable social groups and the poorest of the poor. Even if official fees are exempted or waived, the poor and vulnerable still end up having to pay for drugs, transport, small charges (e.g. cards, materials), and bribes. The exemption scheme is poorly implemented partly because accountability mechanisms are not in place, and because health service providers are not following procedures that are often unclear to them to begin with. But an equally important factor is the low uptake and lack of insistence on free services by the poor, primarily because they are not aware of their rights. A lack of clear criteria and policy guidelines for identifying people who are eligible for waivers has resulted in ad hoc decisions, without clear records or follow-up. How poor people cope: Many poor households have fallen deeper into poverty as they end up using their limited and critical assets to pay for treatment. They use meagre savings (if they have any) and sell their crops, animals, land and their labour. Those who can, borrow money or take a loan, or bond their assets. They are often forced to reduce their food intake and to take their children out of school in order to pay for treatment. These strategies to pay for care drive poor people deeper into poverty and increase their vulnerability significantly. Health care seeking behaviour and choice of providers: Typically, poor people’s incomes are sufficient for subsistence only. They are frequently forced to resort to self-treatment, seek ineffective alternatives, or report much too late for care, often with fatal consequences. Many resort to traditional healers. If people can afford treatment at all, government facilities are normally the only option, especially in rural areas, as they may be close by and possibly less expensive. The overall feeling, however, is that if money can be found it is best to spend it at mission facilities which are generally known for staff commitment and availability of drugs and tests, but perhaps most importantly, for their willingness to defer payment and start treatment if necessary. The way forward The health sector is seriously under-funded despite the fact that it is a priority sector in the Poverty Reduction Strategy, and despite the fact that a healthy population is a basic ingredient of economic growth. Lack of funds, however, is not the only cause of the weak health system. Underskilled and de-motivated personnel, deficiencies in quality of care, weak and confusing management systems, lack of information provided to health consumers, and lack of access by the very poor to treatment characterize much of the current situation. These factors, and more, have resulted in a health care system that requires not only massive investments of funds but also a renewed commitment funds but also a renewed commitment and vision among all actors – government, policymakers, donors, non-governmental organizations, faith based organizations, health workers themselves and others – to generate fundamental change. This call for change is a particular imperative for Tanzanians living in poverty, for whom treatment is becoming increasingly unavailable, and for whom expensive private care is simply not an option. The dilemma, then, is how to make quality care available to all – including the poor – in an environment of limited and insufficient financial resources and severely constrained human and material resources. A number of questions have been raised in this report that merit immediate consideration: What mechanisms can be instituted to minimize the exclusion of poor and vulnerable persons from health services while recognizing the very real financial requirements of the sector? What are the main priorities for improved quality of care for the poor? Affordable services? Available essential drugs? Well-equipped facilities? A motivated team of skilled health workers? How can existing cost structures be revised in order to increase poor people’s access to quality health care? How can an effective mechanism of waivers and exemptions be instituted and enforced? How can problems of access to health facilities be addressed, including distance and affordable transport? How can the referral system be improved so it functions effectively even in rural areas? How can ordinary people get access to adequate and understandable information about allocations and expenditures at the local level? How can people be included in monitoring of health services and ensuring services are\ud \ud \u

Effects of Payment for Performance on accountability mechanisms: Evidence from Pwani, Tanzania.

Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountability mechanisms. We examined the effect of P4P in Tanzania on internal and external accountability mechanisms. We carried out 93 individual in-depth interviews, 9 group interviews and 19 Focus Group Discussions in five intervention districts in three rounds of data collection between 2011 and 2013. We carried out surveys in 150 health facilities across Pwani region and four control districts, and interviewed 200 health workers, before the scheme was introduced and 13 months later. We examined the effects of P4P on internal accountability mechanisms including management changes, supervision, and priority setting, and external accountability mechanisms including provider responsiveness to patients, and engagement with Health Facility Governing Committees. P4P had some positive effects on internal accountability, with increased timeliness of supervision and the provision of feedback during supervision, but a lack of effect on supervision intensity. P4P reduced the interruption of service delivery due to broken equipment as well as drug stock-outs due to increased financial autonomy and responsiveness from managers. Management practices became less hierarchical, with less emphasis on bureaucratic procedures. Effects on external accountability were mixed, health workers treated pregnant women more kindly, but outreach activities did not increase. Facilities were more likely to have committees but their role was largely limited. P4P resulted in improvements in internal accountability measures through improved relations and communication between stakeholders that were incentivised at different levels of the system and enhanced provider autonomy over funds. P4P had more limited effects on external accountability, though attitudes towards patients appeared to improve, community engagement through health facility governing committees remained limited. Implementers should examine the lines of accountability when setting incentives and deciding who to incentivise in P4P schemes

Pay for performance: an analysis of the context of implementation in a pilot project in Tanzania.

BACKGROUND: Pay for performance schemes are increasingly being implemented in low income countries to improve health service coverage and quality. This paper describes the context within which a pay for performance programme was introduced in Tanzania and discusses the potential for pay for performance to address health system constraints to meeting targets. METHOD: 40 in-depth interviews and four focus group discussions were undertaken with health workers, and regional, district and facility managers. Data was collected on work environment characteristics and staff attitudes towards work in the first phase of the implementation of the pilot. A survey of 75 facilities and 101 health workers were carried out to examine facility resourcing, and health worker employment conditions and job satisfaction. RESULTS: Five contextual factors which affect the implementation of P4P were identified by health workers: salary and employment benefits; resource availability, including staff, medicines and functioning equipment; supervision; facility access to utilities; and community preferences. The results suggest that it is important to consider contextual issues when implementing pay for performance schemes in low income settings. It highlights the importance of basic infrastructures being in place, a minimum number of staff with appropriate education and skills as well as sufficient resources before implementing pay for performance. CONCLUSION: Health professionals working within a pay for performance scheme in Tanzania were concerned about challenges related to shortages of resources, limited supplies and unfavourable community preferences. The P4P scheme may provide the incentive and means to address certain constraints, in so far as they are within the control of providers and managers, however, other constraints will be harder to address

Strengthening accountability for better health outcomes through understanding health-system bottlenecks: insights from Tanzania

Corruption is a worldwide concern. Within Tanzania, the landmark Warioba report (URT, 1996) confirmed the existence of extensive corruption across all sectors of the country, including in the public health sector where corruption has been reported at almost every stage of care-seeking. Based on an in-depth review of peer reviewed and grey literature, and complemented by key informant discussions with selected health-system stakeholders, this study seeks to deepen our understanding of informal practices amongst frontline public health providers in mainland Tanzania’s health sector, to explore the incentives that give rise to such practices, and to identify current formal and informal accountability and system-strengthening measures. Taken together, this evidence can be used to inform policy and practice in order to constrain such informal practices

Supply-side factors influencing informal payment for healthcare services in Tanzania

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