Tanzania and Zambia’s health system contexts
At independence in 1961 Tanzania developed a national health system that committed the country to provide the mostly non-urban population with access to health services. To meet the health needs of the rapidly growing, largely rural population, the government structured the health system so that ill people were referred from a local first point of contact to increasingly specialised, more central facilities. That multi-tiered, decentralised health system continues to operate to this day.
The ongoing process of decentralisation by devolution in Tanzania is stretching the managerial staff capacity to coordinate activities across the different ministries and fulfil their roles within the Ministry of Health and Social Welfare and the Prime Minister’s Office, which is in charge of the regional administration and local government structures. The health system includes the national level as the overall policy-maker and the regional, district, ward and community levels (where there are health posts) as the implementation levels.
Health systems weakness in Tanzania relate to shortage of human resource with an estimated 0.52 health care workers per 1,000 population, below the WHO recommended 2. 28 per 1000 population . Government per capita expenditure on health is estimated at only US$13 while donor funding plays a significant role .
In 2012 the Zambian government modified the roles and functions of its two main ministries dealing with health. The Ministry of Health was assigned the role of policy- and decision-making for secondary and tertiary hospitals, curative care and training schools, while the Ministry of Community Development, Mother and Child was mandated with the control of primary health care levels and the responsibility of ensuring integration of interventions at that level. To facilitate efficient and effective coordination of activities, sector coordination structures were established at three administrative levels:
Provincial Health Offices (PHOs) are responsible for coordinating health service delivery in their respective provinces,
District Health Offices (DHOs) are responsible for coordinating health service delivery at district level, and
At community level, neighbourhood health committees were established to facilitate linkages between the communities and the health system.
Although the Zambia health system has registered some improvements in the previous 3 years, it still suffers gaps in the different components of the health system . For example, government percapita expenditure on health is only US$46 below estimated requirement to finance a minimum package of health services. Available human resource is still below the WHO recommended minimum threshold .
Tanzania is renowned for its large number of foreign aid partners in comparison with other African countries. Like many low and middle income countries, it has seen an influx of GHIs since 2000 supporting its strategic efforts to fight of HIV/AIDS, malaria and tuberculosis. The prominent GHIs are the US President’s Malaria Initiative (PMI); the US President’s Emergency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM); the GAVI Alliance; the Roll Back Malaria partnership; UNITAID; Stop TB Partnership; and the Global Leprosy Programme.
Some of the prominent GHIs in Zambia are GFTAM; the GAVI Alliance; PMI; PEPFAR; the Global Alliance for Improved Nutrition; Children’s Investment Fund Foundation; the Measles Initiative and the Global Polio Eradication Initiative.
In Tanzania, GHIs commonly have their own governance structures operating through committees they specifically create to serve their interests. For example, GFATM operates through country coordinating mechanisms that comprise a range of stakeholders, including public and private CSOs. The GAVI Alliance uses an interagency coordinating committee to oversee and make decisions on proposals and support. This committee has representation from both public and private entities. Other GHIs such as the Roll Back Malaria Partnership and Stop TB Partnership operate through United Nations agencies. All United States based GHIs are housed under the Center for Disease Control and Prevention (CDC).
Many of the GHIs in Zambia, including GFTAM and the GAVI Alliance, do not have offices in the country but operate through committees that are mandated to plan for and determine the priorities for grant proposals. Other GHIs operate through multilateral agents like WHO. All United States based GHIs have staff responsible for programme planning and implementation at the national level. In both countries, none of the GHIs uses existing SWAp mechanisms for planning for and financing of the health sector, but they operate through their own structures, which was a concern, as noted by one of the respondents,
SWAp is a very good structure that has been in place for many years now. However, these strong GHIs do not make use of it … Like we are here in this meeting preparing our annual plan but they are not participating. (MoH officer, Zambia)
National health strategic plans and national priorities
In Tanzania, the third health sector strategic plan that was published in 2008 by the Ministry of Health and Social Welfare is the key policy document for the health sector for the period July 2009–June 2015. It serves as the guide for planning at council and hospital levels for the achievement of the national goals of the national programme for economic growth and poverty reduction and the Millennium Development Goals. It includes 11 strategies related to health service delivery, covering district health services; referral hospital services; central level support; human resource for health (HRH); health care financing; public–private partnerships; maternal, new-born and child health; prevention and control of communicable and non-communicable diseases; emergency preparedness and response; social welfare and social protection; and monitoring, evaluation and research.
Zambia’s national health strategic plan 2011–2015 refers to a set of strategies for the development of the health sector over 5 years. It serves as an overarching policy framework for all health service activities within the broader framework of the national policy set out in the sixth national development plan 2011–2015, and the national decentralisation policy (2003). The national health strategic plan is operationalised through the medium-term expenditure framework and annual activity-based budgets.
Perceptions of GHIs contribution to NHSP by Tanzanian and Zambian stakeholders
In Tanzania, most of the stakeholders perceived the GHIs to be aligned with the third health sector strategic plan and to have played a major role in the control of epidemics communicable diseases such as HIV/AIDS. However, some stakeholders remarked that service delivery approaches by the GHIs contributed to inequity among the population owing to prioritisation of a few diseases and areas. Others believed that the GHI contribution to the national strategic plans was only partial, since often their services were not as comprehensive as required in the strategic plans.
Development partners in Zambia have been supporting the implementation of the national health strategic plan by providing resources to the MoH through the expanded health and human resources baskets and through sector budget support. They also support the poverty reduction budget through un-earmarked funds for the Ministry of Finance and National Planning. All the stakeholders believed that the GHIs were aligned with Zambia’s national priorities, since they bought into the country’s development plan, they used the country’s national health strategy as a guide and they collaborated with district health teams in implementation of activities. One of the MoH officers noted that,
Development partners through SWAp are dedicated to support Zambian development plans. We plan together and make sure that we do not duplicate activities.
In both countries the stakeholders indicated that most of the proposals submitted to the GHIs referred to the priorities, objectives, strategic directions and programmatic approaches of the national health development plans. This can be of great value in enhancing coherence between proposals and the countries’ medium- and long-term plans if the health development plans are new or updated. Often, however, the existing national health development plan is old with most of its strategic elements outdated. In such cases, reference to it could result in discrepancies between the proposals submitted to GHIs and the country’s real situation. This indicates the need for government authorities to ensure that their national health development plan is current.
GHI contribution to health system strengthening
In Tanzania, some GHIs such as PEPFAR have been involved in strengthening the management capacity of health leaders at the sub-national level in the effort to address the weaknesses they have noticed in governance. This has involved capacity building for better planning, accountability and performance through a training programme called WAJIBIKA. However, according to the respondents, these efforts are limited and unsustainable, as governance is a government responsibility and needs to be based on a clear road map. Such a road map does not exist in Tanzania, and evidence shows that the Tanzanian government is hesitant to develop it.
Following the misappropriation of funds at the MoH in Zambia that was revealed by the Anti-Corruption Commission and the forensic audit by the Office of the Auditor General, the management of GFATM was moved from the government to the United Nations Development Programme in 2009. This was an interim arrangement as efforts were being made to improve MoH governance and financial and procurement management. A detailed governance plan was developed supported by the Global Fund, donors and other GHIs. The features of the plan were outlined as:
Development of the governance plan
The Government of Zambia developed a governance action plan to help strengthen internal control systems at the Ministry of Health and restore confidence in it in the short and medium terms, while substantial changes would be defined following the implementation of a full systems audit. The action plan was developed by the government together with partners. The plan included the following interventions:
Build capacity within procurement, accounts and internal audit units;
Re-establish and strengthen the role of the audit committee;
Undertake a systems audit of the accounting, auditing and procurement functions;
Strengthen transparency and accountability in financial management;
Strengthen checks and balances systems in the flow of funds;
Streamline the accounts structure of government;
Strengthen oversight of the use of resources in the sector (resource allocation steering committee);
Take legal action on suspected fraud.
Progress made in the implementation of the plan includes:
The integrated financial management system and Navision system have been installed and are operational;
Financial management, accounts, internal audit and procurement systems have been strengthened;
Positions and reporting arrangements for the accounts, internal audit and procurement units have been realigned to ensure greater autonomy and accountability;
A records management system has been designed and implemented;
Audit charter and audit programme and planning formats have been designed and implemented;
A debit card system has been designed and implemented;
The number of outstanding imprests has been reduced to a fifth, and imprests are retired in line with the financial regulations.
The efforts to put the plan in motion have lagged behind because the government is involvement in developing some of its components such as the integrated financial management system, which is deemed to be an expensive venture. Further, the response to the auditor general’s queries has not been timely, and monitoring and evaluation of the procurement processes to ensure proper governance has not matched the goals. By involving CSOs in activities, GHIs have influenced their role in advocating for beneficiaries and to some extent in holding the government accountable in certain areas.
In both Tanzania and Zambia most GHIs have promoted civil society and community participation through concrete project funding or involving them in management mechanisms such as country coordinating mechanisms (CCM). The has resulted in improved community awareness on priority health problems, diversification of providers, and expansion and diversification of national actors engaged in promotive, preventive and curative health services. However, these efforts are not matched with an increase in the regulatory and quality control functions of the national authorities.
In Tanzania, the GHIs’ stringent requirement for financial accountability and timely disbursement of funds has forced them to develop and depend on their own systems, which by default has weakened the national financial systems. This is because there is a tendency to use the same human resources that the health sector relies on, but these are already limited and overburdened. The stakeholders felt that the GHIs had not used their financial power to end corruption in Tanzania, citing cases where evidence of embezzlement of GHI funds was available, e.g. in a GFTAM case, but action had not been taken to deal with the culprits.
The GHIs in Zambia have influenced financial management at the national level through participating in the development of the governance and management plan, but these efforts have concentrated on the central level with little attention on the sub-national level. The government is working to introduce new systems, but these are very expensive and have little support from the GHIs.
Health Information Systems
In Tanzania, GHI support helped make substantial improvement to the health information systems. Furthermore, the mother Health Management Information System, on which all the GHIs depend, has been used to develop other specific GHI health information systems such as the antiretroviral (ART) patient tracking and human resource information systems. However, the longstanding problem of poor data use for planning and decision-making has not seen similar positive changes in Tanzania.
Similarly, interest from the GHIs and donor partners to strengthen the health information systems in Zambia has been high. A partnership between the European Union and GFTAM supported the development of the web-based health information systems in the country.
Human Resources for Health
Most GHIs in Tanzania have and continue to support pre-service and in-service training of HRH, as well as incentives such as housing and top-up allowances. According to the respondents, however, this support is not comprehensive enough since it does not cover the whole HRH spectrum from their production through their recruitment to their retention.
GHIs were regarded to have contributed to the distortion of the HRH market, which has resulted in internal staff attraction to some of their programmes such as pay top-up, and external migration from the government to nongovernmental organisations, which offer better remuneration. The differential payment arrangements from the GHIs have enhanced the culture of working for what is paid, as one respondent noted,
Since the advent of GHIs we have seen a lot of health workers leave the government to work for these initiatives … even those who are still in the public sector prefer to work in their projects because there are always additional incentives. (MoH officer, Tanzania)
The GHIs in Zambia have supported some important initiatives for HRH, given their dire situation, including capacity building, e.g. for clinical specialists, and support of HRH retention schemes and pay for performance initiatives. However, GHI support for HRH has been limited by inadequate staffing, the limited capacity of some of the existing HRH, and government restrictions on salary payments, and other limitations such as task-shifting policies.
Medicine and technology
The GHIs in Zambia have made a huge contribution to the availability of medicines and other health essentials. This has been possible through facilitation of direct purchases of drugs and vaccines, strengthening of supply chain management systems, support of strategies to reduce stockouts, and availing flexible funds for the purchase of drugs when needed. However, GHI efforts have been constrained by the huge size of the country and the under-functioning logistics system.
GHIs have been instrumental in the improvement of service delivery for some key diseases like HIV, tuberculosis and malaria. This has been through their support to the various areas of the health system. GHIs have increased access to health services through working with nongovernmental organisations and CSOs, which have access to the beneficiaries such as people living with HIV/AIDS, and also work in remote areas. Further, GHIs have helped to build the capacity of some key staff necessary for the delivery of services such as HIV counselling and testing, as well as to develop or improve the infrastructure required for delivering some of the services, such as medical laboratories. This has made it possible to deliver and integrate other related services such as cervical cancer screening. But these efforts have been restrained by inadequate HRH capacity, inconsistencies across the GHIs, poor support systems and high staff turnover. One of the negative aspects is the fact that these efforts are limited to a few diseases like HIV, malaria, tuberculosis and vaccine-preventable diseases and do not address other equally important issues such as maternal and child health and non-communicable diseases.
According to the respondents and available data, service delivery for specific diseases such as HIV, tuberculosis and malaria had improved tremendously in Tanzania. But the respondents did not regard these services as sustainable since they mostly depended on GHI funding, which was shrinking all the time. There were concerns that the GHI approach of focusing on selected diseases contradicted Tanzania’s health for all policy and exacerbated equity gaps in service delivery. Additionally, GHI interventions do not address the downstream issues that are the root causes of the diseases they focus on, so they were viewed as superficial and non-holistic.
SWOT (strength, weakness, opportunity and threats) analysis of GHIs
In Tanzania, GHIs were perceived as committed and aligned with the health sector’s strategic plan. Likewise, the main strength of the GHIs in Zambia is that they are aligned with the government’s policy requirements. This has facilitated the attainment of some important goals by Zambia such as the MDGs. The respondents recognised that GHIs had helped raise the profile of some neglected diseases and health areas. An additional advantage associated with the GHIs in Zambia was their ability to mobilise funds for the government.
The respondents believed that efforts to coordinate and harmonise GHIs in Tanzania had not been successful. Some GHIs such as GFTAM and PEPFAR were regarded as particularly difficult in this regard. Further, these efforts were mainly directed and concentrated at only the planning level. The respondents lamented the duplication of activities at the implementation level for example in the running of workshops, which overwhelmed the districts. Also the GHIs’ failure to integrate the existing SWAp mechanisms was seen as partly responsible for the fragmentation and ineffectiveness of donor coordination in Tanzania, as one respondent noted,
One of our biggest challenges is integrating activities at the district level. To date we still operate in silos both from donors and within the Ministry of Health … you can imagine the detrimental effects it has at the district level. (Development partner representative, Tanzania)
One of the main weaknesses in most GHIs is the uncertainty and unpredictability of their funding. The proposal writing processes, despite being intense and time consuming, does not guarantee successful grant funding or funding as per plans. The respondents stated that since most GHIs were not transparent, it was difficult to include them in countries’ plans. The poor harmonisation of GHIs has led to duplication of effort, since local governments exploit this gap to create opportunities for extra personal incomes like per diems from workshops. Duplication of activities has also led to double counting of outcome indicators. The respondents believed that GHIs were limited to an advisory role and rarely influenced legislative processes.
Some good case studies exist that could be used to strengthen GHI functioning. For example, in Tanzania the positioning of a GFTAM liaison officer at the PEPFAR office has resulted in joint planning between these GHIs. The intention and willingness of the GHIs to coordinate activities is an opportunity for the Tanzanian government to initiate similar harmonisation efforts for all GHIs through leadership and guidance. The recent -Big Results Now- renewed effort towards improved performance and accountability is an opportunity to streamline Tanzanian health financing and priorities. Also, Tanzania’s economy is booming, with a rising gross domestic product, providing an opportunity to improve on existing government workforce salaries and incentives for better motivation and performance.
In Zambia the separation of roles of the MoH and the Ministry of Community Development, Mother and Child is an opportunity for better planning and implementation of comprehensive interventions that also tackle the social determinants of health. Zambia’s gross domestic product also has improved, moving the country from a low to a middle income nation, which means that GHIs will call for co-financing of programmes by the government for sustainability.
The biggest threat to GHI functioning and return on investment is the poor status of the workforce through which they implement their interventions. The health workforce in Tanzania’s public sector is generally demotivated owing to poor pay and incentives, and consequently many workers use large portions of their work time on activities to supplement their income. This has led to corruption; poor performance, customer care and service delivery; duplication of activities and nepotism.
The existing GHI approaches in Zambia will continue to distort the planning and implementation of activities. At the district level these approaches have had dire effects on adherence to plans owing to the unpredictability of funding.