UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH AND SOCIAL WELFARE

15TH ANNUAL JOINT HEALTH SECTOR REVIEW FOR 2013-2014
Summary Report of the Technical Review Meeting

5thand 6th November 2014

TABLE OF CONTENT

ITEMPAGE

  1. INTRODUCTION 3
  2. HEALTH SECTOR PERFORMANCE PROFILE REPORT FOR 2013/14 4
  3. BIG RESULTS NOW (BRN) 7
  4. THE NATIONAL HEALTH ACCOUNTS (NHA) 7
  5. UPDATE ON PUBLIC EXPENDITURE REVIEW (2013-14) 8
  6. PERCEPTIONS ON PETTY CORRUPTION IN THE HEALTH SECTOR - 9
  7. HEALTH SECTOR STRATEGIC PLAN IV 10
  8. SUMMARY ANALYSIS OF CCHP 2014-2015 PLANS 10
  9. STATUS OF RHMT PLAN -2014/15 & PERFORMANCE 2013/14 12
  10. FEEDBACK FROM RMO/DMO MEETING 2013/14 12
  11. TANZANIA HEALTH FINANCING STRATEGY 2014-2025 13
  12. RESULT BASED FINANCING FOR HEALTH IN TANZANIA 14
  13. SECTOR WIDE APPROACH-MILESTONES, TWG –REPORTS 15
  14. POLICY ISSUES 16
  15. CLOSING SESSION17

LIST OF TABLES

TABLE NOPAGE

  1. Selected indicators below and on target4
  2. Health service indicators4
  3. Health service indicators not on target 5
  4. Revenue collection achievements 12
  5. The RBF functions allocation 14

LIST OF FIGURES

ITEMPAGE

Figure1Map Human resource distribution5

Figure 2CHF coverage, 2010/11 – 2013/148

  1. INTRODUCTION

Meeting Objective

A two day Technical Review Meeting (TRM) for the 15th Joint Annual Health Sector Review (JAHSR) was held on 5th and 6th November 2014 at Kunduchi Beach Hotel. The broad objective of the meeting was to review the progress made since the last JAHSR–TRM, raising and discussing issues in preparation for the coming JAHSR-Policy Meeting scheduled in the same month of November 2014. The TRM received broad based and inclusive participation from across the country with Sector–Wide Approach (SWAp) stakeholders.

CMO’s welcome address

The Welcome Address was given by the former Chief Medical Officer, now the current Permanent Secretary for MOSHW. Following the introductory remarks he noted the ‘high priority areas’ as.

  1. Efficient and strong Health Systems: The health projects which deliver health outcomes require strong health systems. Evidence of measuring impact: There is great need to measure our performance and results.
  2. Equitable access to essential care: The relevance and effectiveness of the health sector work is measured by its impact especially on women and children. Policy issues: That ensures benefits of economic growth are evenly distributed and public policies that make universal coverage, high quality care and social protection for all.

Permanent Secretary- opening remarks

Fulfilling the role of opening the TRM the former PS welcomed the reviewers, and indicated that this review was unique as it was the time to prepare for the next HSSP IV while winding up the current HSSP III.

Appealing for full cooperation and active participation during the performance assessment the PS, listed a number of challenges facing the sector, he zeroed in on a serious resource gap currently facing the sector. As a strategy he proposed to;

  1. Strengthen the existing, and develop new alternative, financing mechanisms to secure more financial resources
  2. secure additional funding to the sector
  3. Prepare evidence based plans that are realistic and implementable at all levels

Meeting schedule

In total there were six presentations for day one and three for day two. In between presentations there were two panel discussions. The SWAp Milestones 2013/14 and 2014/15 were covered through gallery walk of posters and Market Place Discussion on milestones. The two day program meeting ended by agreeing on the recommended policy priorities for 2015/16 and official closing remarks from the Troika Chair, APHFTA representative and the Deputy Permanent Secretary of PMORALG who officially closed the Technical Review meeting. What follows below is a brief report and the highlights of presentations, discussion points and issues arising from the TRM two days’ meeting. See annex 1 for TRM timetable. Details of presentations and speeches appear as separate attachments.

  1. HEALTH SECTOR PERFORMANCE PROFILE REPORT FOR 2013/14

Health status indicators

The presentation on the performance report covered the key health status, health service and health systems indicators. These indicators are a reflection and mirror the health as well as the performance of the health sector in the Country and effectiveness of the health sector system.

From the presentation three areas deserve mention in this report. See table 1 below.

Table # 1 Selected Health status indicators

INDICATOR / BASELINE (2008) / LATEST DATA (SOURCE) / TARGET 2015
Neonatal mortality rate (per 1,000 live births) / 32 / 26 (TDHS 2010)
21.4 (UN 2012) / 19
% U5 severely stunted / 38% / 42% (TDHS 2010)
35% (NPS 2011) / 20
MMR per 100,000 live births / (BL 2005) TDHS
578 / 454 TDHS 2010
432 CENSUS 2012 / HSSP III Target 2015- 265

Source: Extracted from presentation

The country continues to be faced with severe stunting, and high maternal deaths.

Health service indicators

The presentation used HMIS and SPD as a way of triangulation for data analysis. The conclusions were that;

  1. Malaria was consistently the leading cause of admission over the last three years, and by a great margin. Proportion of malaria among U5 decreased in 2013 compared with 2012 and 2011 (HMIS).
  2. Malaria, pneumonia and anaemia accounted for two thirds of reported U5 deaths in 2013 while HIV/AIDS, Malaria and TB account for 45% of deaths among 5 years and above

The trends in various health services were presented, see Table 2 below

Table # 2Selected Health service indicators

VACCINE / 2008 Baseline % / 2013 in % / 2015-target in %
DPT / 91 / 84 / 85
Measles / 92 / 92 / 85
TT2 / 85 / 89 / 85

Source: from performance presentation

Vaccination: Given the national average of 89%, the following regions performance was below. Dodoma (59%), Mtwara (52%), Kilimanjaro (51%) and Lindi (49% )

Table # 3 Health service indicators not on target

Health service Indicator / Baseline 2008 / 2013 / Target 2015
Health facility deliveries % / 47 / 61 / 80
Family planning coverage / 20 / 43 / 80

Source: From performance report presentation

Although the performance was poor as demonstrated by the above indicators, some regions did well and yet a number of them performed even below the national average. As for ART coverage there has been consistent growth in Pediatric ART, from 13% in 2011 to 29% in 2013.

Health system indicators

Human Resource for Health (HRH)

With the exception of few regions, most regions were below the national average of 7.4 staff per 10,000 population, for all selected cadres. Regions with very low ratios were; Katavi and Simiyu both 2.5 per 10,000, Tabora 2.9, Geita 3.1, Kigoma 3.3 Rukwa 4.7, and Shinyanga 4.9. Most of these regions lie in the Western area of the country.Manifest inequities (HRH gaps in particular) need corrective measures

Figure # 1 Human resource for Health distribution

DISCUSSION AND COMMENTS

Plenary discussion issues

  • Lack of reliable population denominators for 2013

NBS has not yet published official projections, therefore the “best estimate” denominators were used projections based on the census 2012 data and regional inter-censal population growth. The MOHSW will follow up with NBS to release the population denominators for regional and districts use.

  • Quality of HMIS data was not yet good

The challenges facing the HMIS were under- and delayed reporting, duplicating data collection through use of parallel reporting systems and insufficient capacity for data analysis. It was suggested that MOHSW to work together with key stakeholders to chart out how to minimize challenges and improve data quality and sharing. MOHSW agreed to share analyzed data but not the raw data.

  • Under 5 year children severe stunting

Stunting among children 5 years and under is still a major problem. Need to improve recording of diagnoses; screen for malnutrition at admission to optimize care and avoid missed opportunities.

  • Low ANC subsequent visit and low hospital deliveries

There is a need to improve quality of services i.e. have a complete service package for the visits, promoting couple attendance and participation, birth preparedness. Improve the ANC supply chain and ensure delivery of quality services. Low ANC subsequent visit was also linked with low level of hospital deliveries. Promoting facility deliveries was related to having adequate skilled service providers, adequate and quality friendly services.

Panel discussion

  • Population Projection:
  • The MOHSW need to bring to NBS the issues we have in the health sector and what is accommodated in their system
  • Parallel reporting system:
  • Need to strengthen the PPP so that the private providers can be linked with the national system through receiving MTUHA books, and training.
  • Work with CCHPs to include funds into their budgets for printing so that they can order their MTUHA books like ordering logistics.
  • Supportive supervision
  • Supportive supervision and mentoring should focus on quality, effectiveness and follow up of recommendations of previous visit.
  • Ensure that the regional and district teams do not conduct the same activities, but once a regional team visits the facility the district team should go to follow up the implementation.
  • Performance indicators
  • We are seeing low performance in a number of health indicators – what can we do? With such a HRH gap, HSS is critical, so we really need to move forward to provide clarity on plans for community health workers/system. For example, will CHWs be volunteers or a formalised position?
  1. BIG RESULTS NOW (BRN)

BRN result areas

BRN is about improved prioritisation, focused planning, resource management, accountability, and efficient implementation mode. BRN initiatives will form an integral part of HSSP IV. Four result areas agreed are; ensuring a more equitable distribution of HRH; ensuring availability of health commodities; strengthening , performance management; and improved Mother and Neonatal Child Health (MNCH).

Discussion areas

5.4.1Human Resources for Health (Permits)

The issue raised was whether re-distributing HRH was not depriving those councils which had planned properly. Noted that 9 regions below national average must be supported to reach at least the national average, and get rid of dispensaries that have no staff. This may require 90% utilization of employment permits, unfortunately the permits come out at different times from graduation, so you need the permits early enough before they graduate. The solution is to re-distribute the budgets for approved positions that cannot be filled in the market, to other positions. Another area is to look at the production of the health professionals, so that all who have graduated from the schools can be absorbed.

  • Star rating

Star rating basically is performed using a checklist where all health facilities are rated across areas such as; organization, management, clinical care, infrastructure, social accountability, clinical services. The tool has been tested already in Kisarawe District Council, and the conclusion is that this is doable, However, the rating will keep changing as higher levels of quality are reached.

  • Costs for Big Results Now

Money will come in part from the existing budget., Some MNCH activities are already funded by DPs, and that is counted as part of the BRN budget. The costs for some activities can be incorporated within the CCHP. There should be a guideline from Ministry of Finance. It was noted that re-alignment of existing Government and DP budgets will be required to finance BRN priority activities.

  • Roles in BRN

Health care is one of the National Key Result Areas (NKRA) and in order to achieve the results, MOHSW collaborates with PMORALG, MOF and POPSM. Modalities for how to work together will be elaborated. The BRN in health sector is similar to other sectors where PMORALG is involved.

  1. THE NATIONAL HEALTH ACCOUNTS (NHA)

After differentiating the NHA and PER concepts, the presenter provided a brief history of NHA which started in Tanzania in 2001. The methodology of conducting NHA 2011/12 was explained. The following were noted:

  • Total Health Expenditure (THE) has increased from TZS 2,323 billion in 2009/10 to TZS 3,364 billion in 2011/12
  • Government Health Expenditure (GHE) has remained at an average of 7% of Total Government Expenditure
  • Per capita spending has increased from TZS 54,529 in 2009/10 to TZS 71,428 in 2011/12
  • Donors remain the main financiers of THE, contributing an increased share of 48% in 2011/12
  • Government Health Expenditure (GHE) has remained at 21% of THE
  • Out of pocket share has decreased from 32% to 27%, which is still high. There is need to establish effective pre-payment schemes in context of overall Health Financing Strategy.
  • In 2011/12 HIV/AIDS, TB and malaria together account for 45% of Total Health Expenditure, while Reproductive and Child Health accounts for 12%. There is a need to ensure that there is a balance in distribution of resources across diseases while increasing the focus on non-communicable diseases.
  • The share of other private sector (companies) remain negligible, at 3%
  • Role of NGOs in managing sector resources is significant; the Government should establish mechanism for improved monitoring of their operations and impact
  • As regards to the THE by provider, 2002/03 - 2011/12, the hospitals and lower level facilities accounted for 57%, where prevention fell to17% from 23.8% in 2009/10, while administration rose to 13% from 5.9% in 2009/10
  1. UPDATE ON PUBLIC EXPENDITURE REVIEW (2013-14)

As a concept Public Expenditure Review (PER) was differentiated from NHA, in that PER captures expenditure flow for public funds, ie funding that go through the Exchequer system, including donor funding. The PER focuses on the current pertinent issues. The following were noted;

  1. The trend in actual per capita health spending indicates slight increase to over US$ 17 per capita in nominal terms
  2. The trend on budget execution increased from 75% in 2010/11 to 87% in 2013/14, with about 5% increase from 2012/13

Considering the NHIF payments by ownership, the Faith Based Organisations (FBOs) are taking lead of 38%, government is 28% whereas the private is 33%. Private/FBO takes up 70%. This is an area of challenge.

Figure 2 CHF coverage, 2010/11 – 2013/14

CHF coverage has picked up since FY 2012/13, though regional variations remain. A number of regions were below the national average of 8.7% such as Geita, Simiyu and Kagera with a CHF coverage of 1.3%. Singida was leading at CHF coverage of 29.8% followed by Mbeya.

Source: NHIF data on no of households, combined with Census extrapolations for population cover

Comments and Discussion for NHA/PER

  • CHF coverage

Comment:

  1. There is regional disparity as per data presented; a suggestion was made on the possibility of having per capita income and expenditure data at the regional and even district level.
  2. The national income per capita is used at the international level as a criterion to establish whether a country was middle or low income.
  3. Donor dependency was a challenge, which is partly a reflection of not optimizing the CHF window. So it was important to go down to lower levels to have more information.
  4. A decline in spending on prevention was noted
  5. The Mbeya experience with CHF was welcomed, as they were performing well next to Singida. CHF coverage in Mbeya was 1% in 2011 and in 2014 it was 25%.
  1. PERCEPTIONS ON PETTY CORRUPTION IN THE HEALTH SECTOR -

Methodology: The Petty corruption study which was conducted by SIKIKA from 10 districts in Tanzania. Few quotations as testimonies from the citizen and the conceptual framework used were displayed. The methodology involved; Cross-sectional design – districts fixed random sample and Semi-structured questionnaire. In total the following were involved; 1854 outpatients, 485 inpatients, 100 governing HF members, 155 management members of HF, 20 focus group discussions.

Conclusion:

  1. About 67% of community members suspect that health workers steal and sell medicines and equipment.
  2. About 74% of in-patients would go to the same public health facility despite experiencing corruption because they cannot afford alternative health care services.
  3. About 50% of community members indicate that limited accountability contributes to corruption to a “great extent”.
  4. About 62% of members of health facility governing committees admit that they do not follow up patients’ complaints about corruption.

Comments and discussion

Comment:

If a citizen is able to give a bribe of 5,000 what is preventing the person from joining the Community Health Fund?

Response:

  1. The importance of CHF is not believed by people. If they pay in advance they will not get quality services, if they are enrolled in the scheme, they still experience medicine shortage.
  2. The work done at Kibaha, indicates that where the management is able to improve management of CHF funds, then enrollment improves.
  3. Health Facility Governing Committees and the community at large should play a key role in helping facilities and patients to fight corruption.
  4. “Tolerance on corruption” should be addressed through putting into application the Client Service Charter
  5. LGAs should take an active role in enforcing sanctions against those proven to be associated with corruption
  1. HEALTH SECTOR STRATEGIC PLAN IV

Progress of HSSP IV preparation

The update on the development of HSSP IV (2015-20) was given by Ag. DPP. The initial meeting was in December 2013, terms of reference were approved in February 2014. Team Leader (TL), sources of funding and budget were discussed by the HSSP IV task force. The decision was already made that BRN plans should be incorporated into the development of HSSP IV. The TL is from outside Tanzania, and will make an inception visit from November 10-21st, where his tasks will include: finalizing the methodology, and technical content of the HSSP IV; showing clear alignment of BRN with HSSP IV; and providing guidelines for inputs from TWG and other groups. In the meantime the TWGs will continue and the plan is to have a draft HSSP IV strategy by end February 2015 and to start implementation by July 2015.

Comments and discussion

  1. Given a busy year with BRN, prioritizing was important, given the lessons learned with MTR 2013 on budget for implementation. It would be useful for partners to sit down to see what to prioritize, between costing and final draft of HSSP IV and make difficult decisions as a group where required. The principles of BRN, timeliness, achievable, analysis, deep diving will be useful to use.
  1. Given the tight timelines, the TWGs have to start working in December 2014.
  1. SUMMARY ANALYSIS OF CCHP 2014-2015 PLANS

Objectives