Decentralized Local Health Services In Tanzania - Urban Institute
INTERNATIONAL DEVELOPMENT REPORTCOMM will work with you to choose an image forthis space. If you’d like to place a suggested imagehere, right click on the photo behind this box,select Change Picture, and insert your image.RESEARCH REPORTDecentralized Local Health Services inTanzaniaAre Health Resources Reaching Primary Health Facilities, or Are They GettingStuck at the District Level?Jamie BoexApril 2015Luke FullerAmmar Malik
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ContentsAcknowledgments1Decentralized Local Health Services in Tanzania2Background2Objective of the StudyAn Overview of Local Health Services and Local Health Finance in Tanzania32Are Health Resources Reaching the Front Line, or Are They Getting Stuck at the District Level?49A More Detailed Look at Local Health Expenditure Patterns16Conclusions and Next Steps21Notes25References27About the Authors28Statement of Independence30
AcknowledgmentsThis report was funded by the Urban Institute. We are grateful to our funders, who make it possible forUrban to advance its mission. The views expressed are those of the authors and should not beattributed to the Urban Institute, its trustees, or its funders.DECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA1
Decentralized Local Health Servicesin TanzaniaBackgroundOver two-thirds of Tanzanians reside in rural areas and rely on local health facilities (such asDispensaries and Health Centers) run by their Local Government Authorities (LGAs) to provide themwith basic health services. Therefore, efforts to achieve major, sustainable improvements in local healthoutcomes 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 thatform 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 ofits total budgetary resources. Roughly one-third of these resources are channeled to LGAs in the formof sectoral block grants in order to fund the salaries of local health workers as well as the operation andmaintenance cost of District Hospitals and primary health facilities. On average, LGAs receive aroundTSH 10,700 per person (roughly USD 6) in recurrent health grants each year. In addition, LGAs receivefinancial resources and in-kind support for the provision of basic health services from a range ofdifferent sources, including—among others—the Ministry of Health and Social Welfare; internationaldevelopment partners; user fees; and Tanzania’s National Health Insurance Fund.Beyond concerns about the limited amount of health resources that find their way to the local level,there are considerable concerns about the ‘horizontal’ distribution of local health resources amongTanzanian LGAs (Boex 2009; Tidemand et al. 2014). Despite the official introduction of a formula-basedrecurrent grant system in 2004, in practice the allocation formulas are seldom applied. It has been welldocumented that some LGAs receive considerably greater health resources than their fair share, whileothers receive much less than their formula-based grant allocation (Boex 2015). For instance, whilePangani District Council receives a Health Block Grant of more than TSH 50,000 per person, there are16 LGAs that receive less than TSH 5,000 per person.Although numerous studies have analyzed the distribution of health resources from the centralgovernment level to the local government level in Tanzania, much less is known about the “last mile” of2ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
health financing in Tanzania: how much—and how—do local health resources trickle down from the1district level to the public health facilities? Given that front-line health services cannot meaningfullyimprove if health resources get stuck at the district level, ensuring that local health finances aremanaged efficiently at the local level is a critical to achieving sustainable improvements in healthoutcomes.Objective of the StudyThe objective of this study is to develop a more thorough understanding of how public health resourcesin Tanzania flow from the district level to front-line primary health facilities. It is through these frontline health facilities that health resources are transformed from inputs (such as health staff and drugs)into outputs (patients attended by clinical staff at primary health facilities) and health outcomes(improved public health status). This study particularly focuses on the allocations and use of recurrentresources at the local level, including expenditures on Personal Emoluments (PE) and Other Charges(OC) funded by block grants and Health Sector Basket Fund (HSBF) allocations.The research questions in which we are interested are various: What share of health resourcesreaches primary health facilities? Do health facilities have a meaningful Health Facility Plan? Are theseplans prepared at the facility-level, or at the district level? Do health facilities receive an indicativeplanning figure within which they plan their priorities? Do health facilities have any discretion over theresources earmarked for spending at the facility level? What obstacles does facility-level staff face inprioritizing or accessing the financial resources that are set aside for providing health services at thefacility level? To what extent do resources indeed get stuck at the local (district) level instead ofreaching the local health facility level?These questions will take on greater prominence over the coming years as the health sector seeksto improve the efficient use of health resources at the local level, including through the introduction(and possibly main-streaming) of results-based finance (RBF).We pursued three separate research strategies in order to explore management of healthresources at the local level. First, we reviewed the available literature and policy documents on thetopic. Second, we conducted a detailed analysis of health finances in six rural LGAs, which were selectedto serve as an illustrative sample of experiences in rural health service delivery and finance. Third, fieldvisits were undertaken to Mkuranga District Council and Morogoro Municipal Council. DiscussionsDECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA3
with district-level health officials and facility-level health staff at these locations provide considerableinsight into how health resources are actually allocated and used.An Overview of Local Health Services and Local HealthFinance in Tanzania2The Structure of the Public Sector in TanzaniaThe public sector in Tanzania Mainland is divided into two government levels: the central government3level and the local government level. The central government comprises the ministerial tier as well asthe regional administration tier. At the ministerial level, the Ministry of Health and Social Welfare(MOHSW) is the lead authority for the health sector. In addition, several other central governmentagencies are responsible for specific health services, most prominently, the Tanzania Commission onAIDS, TACAIDS. At the regional level, Tanzania is divided into 25 administrative regions. These regionsare an administrative extension of the central government. As such, the Regional Medical Officers ineach region are primarily accountable to the MOHSW for providing regional health services and forsupervising the delivery of health services in their region.The local government level is divided into 158 district-level (urban and rural) LGAs. An average LGAhas approximately 300,000 residents and is led by an elected local government council. This is the maingovernment level responsible for the delivery of decentralized public services in the country, including4the delivery of local health services. The most senior local official in the health sector is the DistrictMedical Officer (DMO). The DMO is supported by the Council Health Management Team (CHMT)which is comprised by the DMO and senior local healthcare administrators.The Assignment of Functions and Expenditure Responsibilities in the Health SectorThe assignment of functions and expenditure responsibilities in Tanzania generally follows thesubsidiarity principle, which suggests that public functions and service delivery responsibilities shouldbe assigned to the lowest government level that can perform the function efficiently.The roles and responsibilities of local government authorities are clarified in the Local Government(District Authorities and Urban Authorities) Acts of 1982 (as amended). The law assigns local4ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
government authorities the responsibility to “promote the social welfare and economic wellbeing of allpersons within its area of jurisdiction” and requires LGAs to take all measures “for the furtherance ofand enhancement of the health, education, and the social, cultural and recreational life of the people”(Section 111). The First Schedule of the Act specifically assigns LGAs the authority to “build, equip andmaintain, or grant sums of money toward the establishment, equipment and maintenance of hospitals,health centers, maternity clinics, [and] dispensaries.”The Vertical Organization of Health ServicesIn line with other countries in sub-Saharan Africa, Tanzania has a hierarchically organized public healthcare system. Table 1 shows the distribution of health facilities by type and ownership for 2010. Anoverview of the organizational structure for the delivery of public health services is shown in figure 1.In following the subsidiarity principle, the health sector in general aims to deliver health services asclose as possible to the people. National Treatment Guidelines specify what health services should beoffered at which facility type, and in which cases treatment should be referred to a higher facility level.As a result of the desire to deliver health services close to the community-level, most common illnessescan be treated at the dispensary-level, or at local Health Centers. This is especially true in rural areas,where transportation costs typically prevent residents from accessing either the District Hospital orprivate health services.DECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA5
TABLE 1Health Facilities in Tanzania by Ownership and Facility Type (June 95101836240Health 75,4694,4188601868786,342Source: MOH&SW (2011b).FIGURE 1Organizational Structure for Health Service Delivery in Tanzania MainlandPrimary Health Facilities (PHFs)The two types of health facilities closest to the community in Tanzania are Dispensaries (D) and HealthCenters (HC). There are currently approximately 3,250 public dispensaries in Tanzania, in comparisonto 340 public Health Centers. The formal distinction between Dispensaries and Health Centers is thatwhile Dispensaries exclusive provide out-patient care, a HC should be able to provide around-the-clockcare to patients; therefore, any conditions that require in-patient care are referred from dispensaries tothe nearest Health Center. In reality, however, the distinction is less clear as many Dispensaries havebeen upgraded to provide child and maternal health services. Health centers and Dispensaries are the6ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
frontline in providing primary curative and preventative health services in Tanzania and are the mainsource of health services for the preponderance of the population, particularly in rural areas.Although these facilities operate with some degree of autonomy on a day-to-day basis, they aresupervised by—and fully accountable to—the District Medical Officer (DMO) for all aspects of theiroperations.Since primary health facilities—as well as the District Hospital—fall under the direct responsibility ofthe DMO, the current assignment of functional responsibilities has resulted in a relatively decentralizedassignment of health services to the local government level. However, at the local level itself, controlover the planning and management of health services is quite centralized. The DMO—who is appointedby the Ministry of Health, but formally reports to the local council through the Executive Director—plays an important role in planning, coordinating and implementing the delivery of local health servicesat the local level. The DMO is supported in this role by the Council Health Management Team (CHMT)and guided in this task by central guidelines and instructions. In order to assure the coordinateddelivery of health services at the local level, the DMO and CHMT are required to prepare aComprehensive Council Health Plan (CCHP) that guides the delivery and development of healthservices. Furthermore, a system of committees (at the district level, but also facility-level) has been setup to assure public participation, oversight and accountability over local health services.Local Health ExpendituresThe local government health budget is broken down into six cost centers: Office of DMO Council Hospital Voluntary Agency Hospitals (VAH) and Service Agreements (SA) Health Centers (public or owned by voluntary agency) Dispensaries (public or owned by voluntary agency) Community health servicesThe Comprehensive Council Health Planning Guidelines (2011) provides guidance on thedistribution of the Health Block Grant between these cost centers. For each cost center the percentageDECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA7
allocation range for the combined funding from the health basket and OC of the Block Grant is shown intable 2.TABLE 2Guidance on the Use of Local Health ResourcesCost centerCeiling range for allocation by CouncilOffice of DMO15%–20%Council Hospital /CDH25%–30%Voluntary Agency Hospitals (VAH) *10%–15% (Health basket funds only)Health Centre15%–20%Dispensary20%–25%Community Initiatives2%–5%Source: MOHSW CCHP Planning Guidelines (2011).The CCHP Planning Guidelines also set ceilings for spending HSBF allowances for “supervision anddistribution activities” (maximum 20 percent) and on “Transport” including fuel and maintenance ofvehicles (maximum 20 percent).Although Dispensaries and Health Centers are separate cost centers in the local governmentbudget, individual primary health facilities do not have their own sub-accounts as part of the local5government’s budget accounts. This means that although the council’s financial accounts can be usedto identify how much funding goes to dispensaries and health centers overall, it is not possible toidentity the resources that flow to individual health facilities in the budget. This can therefore beviewed as a potential limitation of any such study on Tanzanian public finance.The Primary Health Facilities are authorized to have a facility-level account for the receipt of user6fees and Community Health funds. However, these accounts are generally not used for receiving ordistributing block grant resources or the HSBF. The CCHP Guidelines (2011: p 37) note that“[a]llocation of the Health Block grants and Basket funds for Health Centres and Dispensaries aremainly not in cash terms ” The CCHP Guidelines recognize that not all primary health facilities mayhave their own bank accounts, as the guidelines instruct that “Health Centres and dispensaries thathave no bank accounts should maintain a vote book”. Anecdotal evidence, however, suggests that it iscommon practice for district officials to manage user fee collections and other facility-level revenues onbehalf of the front-line facilities.8ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
Medical Stores Department (MSD)In principle, all drugs and medical supplies used by public healthfacilities in Tanzania—those funded by the government, as wellas those funded by external resources—must be purchasedthrough the MSD. MSD is classified as an autonomousgovernment department under MOHSW. As such, it has its ownfinancial accounts and its operations are supervised by a Board,which includes representatives from the MOHSW, otherministries and health agencies. Primary health facilities haveMap 1. Location of Sample Districtstheir own facility-level accounts with MSD for the purchase anddistribution of drugs and medical supplies, although it appearsthat in practice, facilities rely on district-level officials to manage their accounts with MSD.In recent years, local health facilities have been permitted to purchase some drugs from privatesector suppliers in case of MSD stock-outs. However, procurement obstacles in doing so have meantthat the procurement of drugs outside of MSD rarely takes place.Are Health Resources Reaching the Front Line, or AreThey Getting Stuck at the District Level?The Comprehensive Council Health Planning Guidelines (2011) suggest that “regular” health resources)should be managed at the council level on behalf primary health facilities. These regular resourcesinclude those provided through the LGA budget, excluding user fees, community health contributionsand reimbursements from the National Health Insurance Fund. While this may be a practical approachgiven the limited administrative capacity at the facility level, placing the responsibility for the planningand control over facility-level health resources with district-level officials can result in these resourcesbeing “captured” by district level officials (Reinikka and Svensson 2004).In order to analyze whether health resources are reaching the front-line or getting stuck at thedistrict level, we obtained and analyzed budget accounts from a sample of six rural councils: Kasulu,7Ludewa, Mbinga, Mkuranga, Nkasi and Ukerewe District Council (map 1). These councils were notselected to reflect a representative sample of rural councils in Tanzania. Instead, the current analysisshould be seen as exploratory in nature.DECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA9
Table 3 presents the basic demographic conditions, and key indicators of primary healthinfrastructure and health services for these sample districts. The descriptive statistics revealconsiderable variations in local conditions and local health services across the national territory inTanzania. Due to variations in access to health facilities, as well other variations in demand and supplyconditions, the utilization of public health services in our sample district varies from 0.63 Out-PatientDepartment (OPD) attendances per person per year (in Ukerewe) to more than twice that rate (1.47and 1.53, respectively) in Nkasi and Ludewa. Unfortunately, no reliable district level health outcomedata are available (e.g., the under-five mortality rate at the district level), making it impossible toestablish a clear link between improvements in local health services to improved local health outcomes.TABLE 3Basic Demographic Conditions, Health Infrastructure, and Health Services in Sample 67,0174,79012,8346,206Averagecatchmentarea (km2)98.6120.148.983.2151.121.787.2Residents /health staff(in thous.)OPD 2.6145.1Source: Computed by authors based on MOH&SW (2011b) and Boex (2015).Note: Health infrastructure and service data are for 2010.For each of these six district councils, expenditure accounts were drawn from each LGA’scomputerized financial management system. The information contains annual budget estimates (budgetamounts) as well as actual expenditures for FY 2013/14. District-level health expenditures wereextracted by cost center (as discussed above), funding source (block grants or health basket funding),and by detailed type of expenditure based on the Chart of Account’s detailed economic classification.Unless otherwise stated, our analysis is based on actual expenditures as opposed to budget estimates.10ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
TABLE 4An Overview of Total Health Expenditures by Cost Center in Selected MT(combined)CentersDispensariesHealthPanel 1. Total health expenditures by cost center (including wage expenditures) - in TZS 1538.9385.9917.23.82,544.9Panel 2. Per capita health expenditures by cost center (including wage expenditures) - in e2,6251,7631,3653,116168,884Panel 3. Total health expenditures by cost center (including wage expenditures) - as % of 15.537.20.1100.0Source: Computed by authors based on LGA budget accounts.Furthermore, table 4 provides an overview of total local health expenditures by cost center in theselected districts, including both wage and non-wage health expenditures. Table 5 provides the samegeneral information, but only including non-wage expenditures.The top panel in each table presents total health expenditure in millions of Tanzania Shillings (TZS)in each of the six local government authorities. Although these figures reflect the total amount ofspending in each council—ranging from TZS 256 million in Nkasi to TZS 1.42 billion in Mkuranga—it ishard to draw any conclusions based on these raw totals, as district population varies considerablyDECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA11
8among the six sample districts. Hence, the second panel in tables 4 and 5 presents the expenditures inper capita (per person) terms.When local health expenditures are expressed in per capita terms, tables 4 and 5 confirm thevariation and inequity in local finances across LGA which were uncovered by previous studies including,most recently, Tidemand et al. (2014). In per capita terms, the highest-spending districts in our sample(Ludewa and Mkuranga) spend 3-4 times more on health services than the lowest-spending districts9(Nkasi and Ukarewe). These variations do not appear to be related in any way to differences in the costof health services. In fact, whereas Mkuranga in Coast Region—the best-off district in our sample—isrelatively close to Dar es Salaam and has relatively good road access (especially when compared to theother sample districts); in contrast, Ukerewe in Mwanza Region is an island-district in Lake Victoria thathas major accessibility constraints.Tables 4 and 5 also provide insights as to the share of local health resources that flows down tofront-line primary health facilities. This is most apparent in panel 3 of tables 4 and 5, which shows healthspending by cost center, expressed as a percentage of total local health spending. Table 4 reveals thaton average, the share of local health expenditures by the LGA for dispensary-level health services is37.2 percent. Considering that the vast majority of rural health services are delivered at the local level,this statistics suggests considerable underfunding of front-line health services. Although theDispensaries Cost Center receives more funding than other cost centers on average, this is not the caseacross all LGAs in our sample; for instance, in Mkuranga the CHMT is the largest cost category, while inUkerewe hospital services attract the largest share of local health resources.12ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
TABLE 5An Overview of Total Health Expenditures by Cost Center in Selected ed)CentersDispensariesPanel 1. Total non-wage health expenditures by cost center - in TZS 0.9177.30.5703.6Panel 2. Per capita non-wage health expenditures by cost center - in 608.62.12,373.0Panel 3. Total non-wage health expenditures by cost center - as % of .318.025.20.1100.0Source: Computed by authors based on LGA budget accounts.Local health spending patterns are considerably different when we only consider non-wageexpenditures, as shown in table 5. Panel 3 of table 5 shows that only 25 percent of non-wage resourcesare spent on dispensary-level health services. It would be easy to blame DMOs and CHMTs forretaining the bulk of non-wage resources for council-level spending (for health administration or on the10District Hospital, which is often under the direct supervision of the DMO). In reality, however, thesituation is more complex as the CCHP Planning Guidelines (2011) specifically instruct LGAs to spendno more than 25 percent of health OC (from health block grants and Health Basket resources) at theDECENTRALIZED LOCAL HEALTH SERVICES IN TANZANIA13
dispensary level. As such, in their current form, the CCHP guidelines may be constraining rather thanpromoting effective front-line health services.Are Adequate Health Resources Reaching the Front Line?There are numerous recommendations and guidelines on how much countries in Africa should spend onpublic health services, such as the Abuja Declaration of 2001, in which African Union countries pledgedto increase government funding for health to at least 15 percent of budget resources. Regardless ofwhether countries should spend 15 percent of their budget on the health sector, or whether the“adequate” amount of health spending is USD 44 or USD 60 per capita (as others have suggested),most African countries fail to spend adequately on public health (WHO 2013; Avila, Conner, and Amico2013). There is a critical question that receives much less attention: of the resources available to thehealth sector, how much should be channeled to the local level? And from this amount, how muchshould be used for the actual delivery of front-line health services? Few if any studies address thisquestion, and no international benchmarks or norms are available to provide guidance on this matter.11Moreover, we want to explore whether the funding that reaches front-line health facilities inTanzania is adequate. Based on the minimal level of local health resources that actually reach the frontline (as revealed by the analysis above), the shortfall of resources at the local level is so obvious that wecan conclude without any further analysis that the resources flowing down to the facility-level are notadequate to fund a desirable level of public health services. In other words, there is no doubt that moreresources need to be directed in support of front-line services to improve overall health outcomeindicators across the board in Tanzania.However, can we draw any conclusions on whether adequate resources are reaching front-linehealth facilities in relative terms? The relative need for the funding of dispensary-level health servicesdepends on several factors, including the relative demand for basic health services at different levels ofthe referral system (e.g., the number of patients at the dispensary level versus the number of patients athealth centers, District Hospitals, etc.); the relative cost of providing health services at the front lineversus health services higher up the referral system; and government priorities in the health sector.12Given the limited availability of data about even the most basic local health finance and local healthservices in Tanzania (particularly at the district level), this question is almost impossible to answerwithout investing significant resources in obtaining relevant information. While the current studyanalyzes local health spending funded by block grants and health basket funding, no comprehensive14ARE HEALTH RESOURCES REACHING PRIMARY HEALTH FACILITIES?
figures are available that show the total amount of funding for local health services, which shouldinclude allocations from MSD for drugs and medical supplies; financial and in-kind support receivedfrom various “vertical programs” managed by the Ministry of Health and Social Welfare; local healthspending funded from local taxes and other own source revenues; spending on health infrastructureand development funded by the Local
The local government level is divided into 158 district-level (urban and rural) LGAs. An average LGA has approximately 300,000 residents and is led by an elected local government council. This is the main government level responsible for the delivery of decentralized public services in the country, including the delivery of local health services.
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