Beyond Antimalarial Stock-outs: Implications of Health Provider Compliance on Out-of-Pocket Expenditure during Care-Seeking for Fever in South East Tanzania.

To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability

An approach to addressing governance from a health system framework perspective

As countries strive to strengthen their health systems in resource constrained contexts, policy makers need to know how best to improve the performance of their health systems. To aid these decisions, health system stewards should have a good understanding of how health systems operate in order to govern them appropriately. While a number of frameworks for assessing governance in the health sector have been proposed, their application is often hindered by unrealistic indicators or they are overly complex resulting in limited empirical work on governance in health systems. This paper reviews contemporary health sector frameworks which have focused on defining and developing indicators to assess governance in the health sector. Based on these, we propose a simplified approach to look at governance within a common health system framework which encourages stewards to take a systematic perspective when assessing governance. Although systems thinking is not unique to health, examples of its application within health systems has been limited. We also provide an example of how this approach could be applied to illuminate areas of governance weaknesses which are potentially addressable by targeted interventions and policies. This approach is built largely on prior literature, but is original in that it is problem-driven and promotes an outward application taking into consideration the major health system building blocks at various levels in order to ensure a more complete assessment of a governance issue rather than a simple input-output approach. Based on an assessment of contemporary literature we propose a practical approach which we believe will facilitate a more comprehensive assessment of governance in health systems leading to the development of governance interventions to strengthen system performance and improve health as a basic human right

Health system governance in Tanzania : impact on service delivery in the public sector

Governance in the health system has perhaps been the least explored building block of the health system, receiving less attention due to its vague definition and complex nature. When discussed at the country level it often focuses on single elements such as corruption or accountability and doesn’t consider wider interactions of relevance to how policies are formed. How well governed a health system is can often mean the difference between the efficient use of resources and inefficient waste, which is even more important in a resource constrained environment. The United Republic of Tanzania has been a major recipient of donor aid over the past few decades. Tanzania’s health sector in particular has been the subject of much donor interest, especially regarding medicines. One of the first donors to support medicines was Danida who funded the essential medicines kit, and since then numerous donors have been involved in either funding medicines, designing policies around medicines selection, procurement and distribution, or direct medicines donations. Although Tanzania has largely benefited from this increase in donor support, not all of it has been designed and implemented adequately to suit the situation and needs of Tanzania. In other words, health systems governance may sometimes have been weakened by donor-interest, resulting in reduced quality of health care. The aim of this research was to contribute to a better understanding of health system governance and apply this knowledge to the Tanzanian health system. The insights gained should aid policy makers and other stakeholders to design interventions that are appropriate for the local context to ensure a stronger health system which is able to attain its goals of improving the level and distribution of health, while responding to the population’s needs and protecting them from large, often catastrophic financial expenditures. The research was carried out as part of the Governance of Health Systems project, a collaborative endeavour between the Swiss Tropical and Public Health Institute and the Basel Institute of Governance. Quantitative and qualitative methods were applied to data collected in two areas of the local Health and Demographic Surveillance System (HDSS), Ulanga District and Rufiji District. We used both primary data collection and secondary data, covering the period from 1999 – 2011. The overall findings are that despite the interest over the past decade to develop frameworks to assess governance in the health system, few have been empirically applied. The first part of this thesis focuses on developing a framework to assess governance in the health system; the second part applies this framework to a selected governance issue in Tanzania, namely the delivery of essential medicines to public health centres in Tanzania. At the national level, this investigation found that the medicines ordering system was based on a complex paper-based system which had not been designed with local capacity in mind, nor did it improve the accountability of medicines. Lack of accountability was also found at the health facility level, where over half of respondents interviewed who sought care in the public sector for fever, subsequently experienced the consequences of one form or another of non-compliant health-worker behaviour (overcharging for treatment and medicines, stocking out of the first line antimalarial, dispensing an inappropriate monotherapy). This resulted in an additional cost to the patient, on average, of USD1.62 per treatment episode, representing 125% of the national per capita daily income, or 164% of the rural per capita daily income. Stockouts of essential medicines are an immediate indicator of governance failure and in the case of fully funded donor medicines, stockouts represent a health system failure. This research identified that in a 15 month period from October 2011 until the end of 2012, an estimated 29% of health facilities were stocked out of the first line antimalarial at any one time. These stockouts were due to failures at the national and international level where excessive bureaucratic procedures resulted in fragmented and dysfunctional procedures for procurement of the first line antimalarial. The findings in this thesis suggest that Tanzania should redesign the medicines ordering system, with greater participation from health workers, in order to better understand the challenges they face. We recommend various interventions across the health system to strengthen it and improve the availability of medicines. The most important recommendation would be to increase accountability and transparency of the medicines delivery system and force reconciliation between data sources thereby creating information on medicines consumed. The findings of this thesis contribute to a more comprehensive understanding of governance in health systems and how overlooking governance can cause major catastrophic stockouts of essential medicines, in addition to a reduced level of service delivery and greater economic hardship for households

Essential medicines in Tanzania : does the new delivery system improve supply and accountability?

Objective: Assess whether reform in the Tanzanian medicines delivery system from a central 'push' kit system to a decentralized 'pull' Integrated Logistics System (ILS) has improved medicines accountability. Methods: Rufiji District in Tanzania was used as a case study. Data on medicines ordered and patients seen were compiled from routine information at six public health facilities in 1999 under the kit system and in 2009 under the ILS. Three medicines were included for comparison: an antimalarial, anthelmintic and oral rehydration salts (ORS). Results: The quality of the 2009 data was hampered by incorrect quantification calculations for orders, especially for antimalarials. Between the periods 1999 and 2009, the percent of unaccounted antimalarials fell from 60 to 18%, while the percent of unaccounted anthelmintic medicines went from 82 to 71%. Accounting for ORS, on the other hand, did not improve as the unaccounted amounts increased from 64 to 81% during the same period. Conclusions: The ILS has not adequately addressed accountability concerns seen under the kit system due to a combination of governance and system-design challenges. These quantification weaknesses are likely to have contributed to the frequent periods of antimalarial stock-out experienced in Tanzania since 2009. We propose regular reconciliation between the health information system and the medicines delivery system, thereby improving visibility and guiding interventions to increase the availability of essential medicines

The challenge to avoid anti-malarial medicine stock-outs in an era of funding partners : the case of Tanzania

Between 2007 and 2013, the Tanzanian public sector received 93.1 million doses of first-line anti-malarial artemisinin-based combination therapy (ACT) in the form of artemether-lumefantrine entirely supplied by funding partners. The introduction of a health facility ACT stock monitoring system using SMS technology by the National Malaria Control Programme in mid 2011 revealed a high frequency of stock-outs of ACT in primary care public health facilities. The objective of this study was to determine the pattern of availability of ACT and possible causes of observed stock-outs across public health facilities in Tanzania since mid-2011.; Data were collected weekly by the mobile phone reporting tool SMS for Life on ACT availability from over 5,000 public health facilities in Tanzania starting from September 2011 to December 2012. Stock data for all four age-dose levels of ACT across health facilities were summarized and supply of ACT at the national level was also documented.; Over the period of 15 months, on average 29% of health facilities in Tanzania were completely stocked out of all four-age dose levels of the first-line anti-malarial with a median duration of total stock-out of six weeks. Patterns of total stock-out by region ranged from a low of 9% to a high of 52%. The ACT stock-outs were most likely caused by: a) insufficient ACT supplies entering Tanzania (e.g. in 2012 Tanzania received 10.9 million ACT doses compared with a forecast demand of 14.4 million doses); and b) irregular pattern of ACT supply (several months with no ACT stock). The reduced ACT availability and irregular pattern of supply were due to cumbersome bureaucratic processes and delays both within the country and from the main donor, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Tanzania should invest in strengthening both the supply system and the health information system using mHealth solutions such as SMS for Life. This will continue to assist in tracking ACT availabili across the country where all partners work towards more streamlined, demand driven and accountable procurement and supply chain systems

Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania

Abstract BACKGROUND: To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. METHODS: We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. RESULTS: Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. CONCLUSION: System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability