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SECTOR WIDE APPROSECTOR WIDE APPROACHES IN TANZANIAACHES IN TANZANIA

THE CURRENT STATUS , THE CURRENT STATUS , CHALLENGES AND SUCCESS CHALLENGES AND SUCCESS

STORIESSTORIES

BY Dr. Faustin Njau BY Dr. Faustin Njau Head, Health Sector Reform Development ProgramHead, Health Sector Reform Development Program

MOHMOHTanzania.Tanzania.

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Characteristics of Health Sector Wide Characteristics of Health Sector Wide Approaches Approaches

Significant funding for the sector supports as Significant funding for the sector supports as a single sector policy expenditure a single sector policy expenditure programme programme

The government provides leader ship The government provides leader ship (Government in Drivers seat !!)(Government in Drivers seat !!)

Adopting common approaches across the Adopting common approaches across the sector and progressing towards relying on sector and progressing towards relying on government procedures to:government procedures to:

Disburse and account for fundsDisburse and account for funds Procure goods, servicesProcure goods, services Monitor progress made to Improve peoples Monitor progress made to Improve peoples

healthhealth

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The government objectives under swapsThe government objectives under swaps

Change in the way the sector is Change in the way the sector is managed, financed and strengthen managed, financed and strengthen dialogue mechanisms or structuresdialogue mechanisms or structures

Shift roles and responsibilities & decentralize to Shift roles and responsibilities & decentralize to lower levelslower levels

Measures that will ensure Measures that will ensure AVAILABILITY,AVAILABILITY, accessibility, quality, affordability, and equity in accessibility, quality, affordability, and equity in provision of health careprovision of health care

Application of effective strategies for Application of effective strategies for community involvement and empowermentcommunity involvement and empowerment

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What does health sector dialogue What does health sector dialogue look like?look like?

Sector reviewsSector reviews

Technical Committee of the SWAp Technical Committee of the SWAp

(TC-SWAp)(TC-SWAp)

Technical Working Groups (TWGs)Technical Working Groups (TWGs)

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Dialogue structure Health SWAPsDialogue structure Health SWAPs Sector Review 9 so far, going to the 10Sector Review 9 so far, going to the 10thth

a (Decade of SWAps in Tanzania) 2009a (Decade of SWAps in Tanzania) 2009 Technical Committee of the SWAp (TC-Technical Committee of the SWAp (TC-

SWAp) every 2 months but more on SWAp) every 2 months but more on demand!!! demand!!!

Technical Working Groups (TWGs) on Technical Working Groups (TWGs) on thematic thematic areas-too many and some areas-too many and some have no value addition, they do not even have no value addition, they do not even meet.meet.

Other meetings/ ‘dialogueOther meetings/ ‘dialogue

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Other meetings/ ‘dialogue’Other meetings/ ‘dialogue’ DP Troika joins monthly senior MOHSW DP Troika joins monthly senior MOHSW

management meetingmanagement meeting Basket Financing Committee – discusses Basket Financing Committee – discusses

issues relating to this financing modality issues relating to this financing modality only.only.

DPG Health meets on the first Wednesday DPG Health meets on the first Wednesday of every monthof every month

Financing committee is more powerful than Financing committee is more powerful than the technical arm. the technical arm. ““Save the money or Save the money or lives is an issue if the MDGs have to be lives is an issue if the MDGs have to be reached.”reached.”

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Swaps 18 years bench marks1991-2009Swaps 18 years bench marks1991-2009

1984 Economic Recovery Programme 1984 Economic Recovery Programme (ERP) resulting in the liberalization of the (ERP) resulting in the liberalization of the economyeconomy

1991 Pharmacy Board strengthened1991 Pharmacy Board strengthened 1993 user charges introduced at National 1993 user charges introduced at National

health facility levelhealth facility level 1994 user charges extended to cover 1994 user charges extended to cover

regional and district hospitalsregional and district hospitals 1995 introduction of user charges to 1995 introduction of user charges to

health centres and dispensaries shelved health centres and dispensaries shelved

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Cont -2 Swaps 18 years bench marks Cont -2 Swaps 18 years bench marks 1991-20091991-2009

1993 health sector performance reviewed1993 health sector performance reviewed

1994 Health Reforms Proposals document 1994 Health Reforms Proposals document preparedprepared

1995 -1996 draft POW and POA prepared1995 -1996 draft POW and POA prepared

January 1998 Joint review of Health sector January 1998 Joint review of Health sector reforms. 9 reviews to date.reforms. 9 reviews to date.

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Cont -3 Swaps 18 years bench marks1991-Cont -3 Swaps 18 years bench marks1991-20092009

May 1998 Statement of Intent ( majority May 1998 Statement of Intent ( majority of Health partners and the GOT ) agree to of Health partners and the GOT ) agree to apply SWAPS during implementation of apply SWAPS during implementation of health sector reformshealth sector reforms

March 1999 GOT and partners endorse March 1999 GOT and partners endorse the MOH three year plan ( July 1999 to the MOH three year plan ( July 1999 to June 2002) and the annual PPOAJune 2002) and the annual PPOA

July 1999 to date SWAps application July 1999 to date SWAps application introduced in phasesintroduced in phases

We are in the HSSP 3 effective from 1We are in the HSSP 3 effective from 1stst of of July 2009.July 2009.

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Phases of HSRPhases of HSR 1.Conceptualization and studies 1.Conceptualization and studies 2.2. Proposals to the government Proposals to the government 3.3. Pre-implementation phase and Pre-implementation phase and

managing changemanaging change Systems development Systems development Strategies and toolsStrategies and tools Setting up committees and bodies Setting up committees and bodies Technical guidelines and protocols Technical guidelines and protocols Legal frame work and structuresLegal frame work and structures Setting up the Health Sector Reform Setting up the Health Sector Reform

SecretariatSecretariat

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Cont –> 2 Phases of HSRCont –> 2 Phases of HSR 4.4. ImplementationImplementation phasing Districts->3phasing Districts->3 MOUsMOUs Code of conductCode of conduct StudiesStudies AdjustmentsAdjustments

We are now at this 4We are now at this 4thth phase towards phase phase towards phase of consoliation below.of consoliation below.

Completion of Reforms and Completion of Reforms and consolidation phase is an anticipationconsolidation phase is an anticipation

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Health sector strategies are 9 but HSSP3 Health sector strategies are 9 but HSSP3 ARE 11.ARE 11.

6.1 Strategy 1-_District health services6.1 Strategy 1-_District health services

6.2 Strategy 2 Secondary and Tertiary 6.2 Strategy 2 Secondary and Tertiary hospital serviceshospital services

6.3 Strategy 3 Role of the Central Ministry 6.3 Strategy 3 Role of the Central Ministry of Healthof Health

6.4 Strategy 4-Human Resources 6.4 Strategy 4-Human Resources DevelopmentDevelopment

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Cont- 2 Health sector strategies are now 9 Cont- 2 Health sector strategies are now 9 but the HSSP 3 are 11. but the HSSP 3 are 11.

6.5 Strategy 5 Health care Financing6.5 Strategy 5 Health care Financing 6.6 Strategy 6 Public Private Partnership6.6 Strategy 6 Public Private Partnership 6.7 Strategy 7 Maternal, New born and 6.7 Strategy 7 Maternal, New born and

child healthchild health 6.8 Strategy 8- Diseases Specific 6.8 Strategy 8- Diseases Specific

ProgramsPrograms 6.9 Emergency Preparedness6.9 Emergency Preparedness 6.10 Social Welfare and Social Protection6.10 Social Welfare and Social Protection 6.11 Monitoring Evaluation and Research6.11 Monitoring Evaluation and Research

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Notable AchievementsNotable Achievements a new resource allocation formula that takes a new resource allocation formula that takes

into account population 70%, poverty count into account population 70%, poverty count 10%, district vehicle route 10% and under five 10%, district vehicle route 10% and under five mortality 10% was developed and is being used mortality 10% was developed and is being used for both Basket and Health Block grants since for both Basket and Health Block grants since 2004 2004

Council Health Services Boards and facility Council Health Services Boards and facility committees have been established in all 132 committees have been established in all 132 local authorities local authorities (but weak management of the (but weak management of the same)same)

We are in the process of establishing We are in the process of establishing Community Health Fund in all the 132 CouncilsCommunity Health Fund in all the 132 Councils

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Cont ->2 Notable AchievementsCont ->2 Notable Achievements

Rehabilitation of health centers and Rehabilitation of health centers and dispensaries started based on joint dispensaries started based on joint rehabilitation manual in phases, rehabilitation manual in phases, this is giving this is giving way to LGDG Health windowway to LGDG Health window

District and Regional hospital reforms have District and Regional hospital reforms have been initiated whose aim is to strengthen been initiated whose aim is to strengthen hospital management, to improve quality hospital management, to improve quality

The MOH has prepared inputs to “ Improved The MOH has prepared inputs to “ Improved quality of life and social well being cluster” of quality of life and social well being cluster” of the NSGRP (MKUKUTA) and we are now the NSGRP (MKUKUTA) and we are now preparing inputs to MKUKUTA 2, preparing inputs to MKUKUTA 2, (20011-2015).(20011-2015).

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Cont ->3 Notable AchievementsCont ->3 Notable Achievements Special review of the Private Public Special review of the Private Public

Partnership has been carried out, Partnership has been carried out, bottlenecks have been identified and it is bottlenecks have been identified and it is expected that concrete action to address expected that concrete action to address this area will be implemented. this area will be implemented.

Capacity development for Regional health Capacity development for Regional health teams to enable them perform their teams to enable them perform their expected roles in support of CHMTs has expected roles in support of CHMTs has been initiated all 21 RHMT have been been initiated all 21 RHMT have been trainedtrained

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Monitoring process of the sectorMonitoring process of the sector The process is carried out through:The process is carried out through:

Quarterly Progress reportsQuarterly Progress reports

Annual financial and technical Annual financial and technical reportsreports

Health Sector Performance profileHealth Sector Performance profile

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Cont – 2 Monitoring process of the Cont – 2 Monitoring process of the sectorsector

Annual Health Sector Reviews, SWAPs Annual Health Sector Reviews, SWAPs and BFC committee reportsand BFC committee reports

Review of comprehensive plans and Review of comprehensive plans and monitoring indicators for progress by all monitoring indicators for progress by all local 121LGAs local 121LGAs

poverty monitoring system (PMS)for poverty monitoring system (PMS)for MKUKUTA –NSGRP.MKUKUTA –NSGRP.

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Sources of monitoring dataSources of monitoring data HMIS HMIS (very weak as yet)(very weak as yet) Study reports commissioned each prior to Study reports commissioned each prior to

the main review as part of technical the main review as part of technical reviewreview

Annual Public Expenditure reviews Annual Public Expenditure reviews Periodic health service delivery surveys Periodic health service delivery surveys

and other surveysand other surveys 8, National sentinel Stations8, National sentinel Stations

2020

Cont – 2 Sources of monitoring dataCont – 2 Sources of monitoring data Demographic health surveyDemographic health survey

National Population CensusNational Population Census

National programme reportsNational programme reports

Annual reports from RMOs, District Annual reports from RMOs, District Medical Officers and Reproductive and Medical Officers and Reproductive and Child HealthChild Health (21 Regions and 132 Districts) (21 Regions and 132 Districts)

National Poverty Monitoring System, Research National Poverty Monitoring System, Research and analysis.and analysis.

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Our Great challenges are:Our Great challenges are:(a) At national level (a) At national level (health systems) (health systems)

issuesissues

1.1. HIV/AIDS Pandemic – in it is a disaster HIV/AIDS Pandemic – in it is a disaster

2.2. Under funding of sector Under funding of sector

3.3. Growing demands due to Burden of Disease Growing demands due to Burden of Disease – TB, Malaria, accidents and other chronic – TB, Malaria, accidents and other chronic illness – Diabetes mellitus, bilharzias, illness – Diabetes mellitus, bilharzias, onchocerciasis, etconchocerciasis, etc

4.4. Human resources for the health care is out Human resources for the health care is out of balance of balance

Management component Management component Health providers in crisisHealth providers in crisis

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Our Great challenges cont->2:Our Great challenges cont->2:5. Maximization of the Private sector is at 5. Maximization of the Private sector is at

minimum level. Attempts have been made minimum level. Attempts have been made to highlight on the PPP through Joint Health to highlight on the PPP through Joint Health Sector Reform all the years Sector Reform all the years

6. Old and dilapidated Health infrastructure 6. Old and dilapidated Health infrastructure

7. Growing digital divide and hence knowledge 7. Growing digital divide and hence knowledge gap especially on specialized professional gap especially on specialized professional areasareas

8. Multiple reforms in the government 8. Multiple reforms in the government

9. Climate Change Climate change 9. Climate Change Climate change (the world (the world is warming up) is warming up) is increasing new epidemicsis increasing new epidemics

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Challenges, -> (b) Development PartnersChallenges, -> (b) Development Partners Coordinating partners is not an easy taskCoordinating partners is not an easy task Policies not flexible when it comes to the Policies not flexible when it comes to the

methods of financing the sector methods of financing the sector (we feel (we feel pushed to comply with int. prescription eg pushed to comply with int. prescription eg Global Funds-ATM)Global Funds-ATM)

Incremental conditionalities continue to Incremental conditionalities continue to loom around and is personality loom around and is personality dependent at timesdependent at times

Parallel systems of procurement, auditing Parallel systems of procurement, auditing and TA is a gray zone. and TA is a gray zone.

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Challenges,->2 (b) Development PartnersChallenges,->2 (b) Development Partners Some have specific areas of their interest and Some have specific areas of their interest and

verticalize the MTEF activities and verticalize the MTEF activities and especially especially the commodities. Shy away from human the commodities. Shy away from human resource issues.resource issues.

Pilots and projects will still exist and Pilots and projects will still exist and programmes are sometimes difficult to pursue programmes are sometimes difficult to pursue in Totoin Toto

Verticalization can be minimized but remain a Verticalization can be minimized but remain a factor.factor.

Institutional memory changes as Institutional memory changes as individuals swap desks or counties.individuals swap desks or counties.

There is a need for the MoU and Code of There is a need for the MoU and Code of conduct to be adhered to as a necessityconduct to be adhered to as a necessity

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(c) Global Changes->cont(c) Global Changes->cont •Unfulfilled promises or financial Unfulfilled promises or financial

commitments (global agreements)commitments (global agreements)•Changing priorities at this level Changing priorities at this level

almost all the timesalmost all the times•Too many meetings and processes Too many meetings and processes

without concerted actionswithout concerted actions•Pressure for parallel systems Pressure for parallel systems

especially when funds are available especially when funds are available (too many NGOs difficult to monitor (too many NGOs difficult to monitor and regulate)and regulate)

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ADDRESS THE CHALLEGESADDRESS THE CHALLEGES Identifying difficult areas and set Identifying difficult areas and set

milestones annually during reviewsmilestones annually during reviews Mobilize more resources for health and Mobilize more resources for health and

maximize on available resourcesmaximize on available resources Enhance monitoring system for Enhance monitoring system for

performanceperformance Capacity building for human resources on Capacity building for human resources on Management Management Service providersService providers Numbers matter!!!Numbers matter!!!

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Cont -2 ADDRESS THE CHALLEGESCont -2 ADDRESS THE CHALLEGES

Match inputs with outcomes (MKUKUTA)Match inputs with outcomes (MKUKUTA) Better coordination and collaboration with Better coordination and collaboration with

our partners, thus building trust and our partners, thus building trust and transparencytransparency

Step up advocacy for reformsStep up advocacy for reforms Focus more on community ownership and Focus more on community ownership and

participation participation (Shares holding in health (Shares holding in health services)services)

Continue with Annual Technical Review Continue with Annual Technical Review and Policy Reviews to market the sectorand Policy Reviews to market the sector

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POVERTY REDUCTION LINKED WITH POVERTY REDUCTION LINKED WITH HSSP AND MDGsHSSP AND MDGs (Planning ahead) (Planning ahead)

It is part of NSGRP – MKUKUTAIt is part of NSGRP – MKUKUTAThe HSSP 2003/08 was positioned in The HSSP 2003/08 was positioned in

MKUKUTA – 9 strategies and three MKUKUTA – 9 strategies and three (3) clusters, HSSP3 we have done the (3) clusters, HSSP3 we have done the samesame

MDGs 1-8 all have a bearing on MDGs 1-8 all have a bearing on health. It is not only MDGs 4,5&6.health. It is not only MDGs 4,5&6.

Impact of climate change on health Impact of climate change on health is not yet fully known is not yet fully known WATCH OUT!!WATCH OUT!!

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CONCLUSSIONCONCLUSSION ThThe health sector is one of the 17 e health sector is one of the 17

reforms going on in Tanzania under reforms going on in Tanzania under the supervision of the government.the supervision of the government.

The sector problems are known and The sector problems are known and the solutions are also known. the solutions are also known.

Resources and willingness at Resources and willingness at different levels still not in place and different levels still not in place and especially at the global level (ODA). especially at the global level (ODA).

A complete paradigm shift is needed A complete paradigm shift is needed and change management mode and change management mode including corporate governance.including corporate governance.

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Cont -2 conclusionCont -2 conclusion But these are the variables which are not But these are the variables which are not

easy to be accepted by all the actors easy to be accepted by all the actors within the same time frame. within the same time frame.

Opportunities have to be realized and Opportunities have to be realized and made advantages of. made advantages of.

The political dimension has to be brought The political dimension has to be brought afore, and advocated at different levels. afore, and advocated at different levels.

Lobbying may be a necessity and building Lobbying may be a necessity and building alliances with those who genuinely alliances with those who genuinely support the health sector.support the health sector.

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THANK YOU FOR LISTENINGTHANK YOU FOR LISTENING