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Applying a Governance Lens to Assess the Health Systems: Maximising Access to Essential Health Interventions. A Focus on Tanzania Masuma Mamdani, Ifakara.

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Presentation on theme: "Applying a Governance Lens to Assess the Health Systems: Maximising Access to Essential Health Interventions. A Focus on Tanzania Masuma Mamdani, Ifakara."— Presentation transcript:

1 Applying a Governance Lens to Assess the Health Systems: Maximising Access to Essential Health Interventions. A Focus on Tanzania Masuma Mamdani, Ifakara Health Institute Regional Summer School Governance for Health Systems Development –Convened by SOAS, University of London in association with IDS, University of Dar es Salaam, 18th-22nd July, Movenpick Hotel, Dar es Salaam

2 2 What is Governance? Process of decision-making and how they are implemented/ not implemented. Focuses on: Process of decision-making and how they are implemented/ not implemented. Focuses on:  formal and informal actors involved in decision-making and implementing  formal and informal structures that have been set in place to arrive at and implement the decision Source: Wikipedia

3 3 What is Good Governance? “….an ideal which is difficult to achieve in its totality….to ensure sustainable human development, actions must be take to work towards this ideal with the aim of making it a reality” UNESCAP “….an ideal which is difficult to achieve in its totality….to ensure sustainable human development, actions must be take to work towards this ideal with the aim of making it a reality” UNESCAP “is important in ensuring effective health care delivery, and that returns to investments in health are low where governance issues are not addressed.” Maureen Lewis, “Governance and Corruption in Public Health Care Systems” CGD Working Paper 78, Jan 2006 ““….is important in ensuring effective health care delivery, and that returns to investments in health are low where governance issues are not addressed.” Maureen Lewis, “Governance and Corruption in Public Health Care Systems” CGD Working Paper 78, Jan 2006

4 4 What is a Health System? Complex, dynamic and ever changing. not static Many issues affect the ability of health systems to deliver - governance, financing, HR, information, access, quality, impacts of reforms in other areas of the economies significantly, etc. Many actors are involved – government, ministries, CSOs, financing agents (global, national), service providers, communities, etc …their perspectives of the system vary.

5 5 Improving a health system has become a balancing act….. Decision makers:   the need for disease specific programmes vs. those targeting the health system as a whole;   national priorities with global initiatives;   policy directives with “street-level” realities “the context”

6 6 Central question: efficient use of available resources towards improved health outcomes for ALL Beyond the Health Sector

7 7 Central question: efficient use of available resources towards effective access to essential life saving health services for ALL A Focus on the Health Sector

8 8 Tanzania’s total health sector budget increased by 37% (nominal terms) from 2006/07 to 2007/08 (PER & MTEF, MoHSW) Est. annual/capita spending on health (USD, nominal): FY FY FY FY FY FY08 Est. health exp. of total govt. exp.: 9.7% FY06 9.7% FY % FY % FY % FY % FY08 Falling short of Abuja target 15% Excludes significant ‘off budget funding’

9 9 Distortions…… “Aid [for HIV/AIDS] increased by three-quarters and now finances 95% of Government plus donor spending. The increase has been from off-budget sources of finance, and only 19% of expected aid in 2007/08 is included in the budget. HIV/AIDS is now taking a staggering one-third of all aid to Tanzania” (IMF ODA data, TACAIDS 2008). Implications for national planning and budgeting? Of establishing a clear link between strategic plans, approved budgets and actual expenditures against goals and targets?…GOVERNANCE? How have and will GHIs shape the system (HIV/AIDS, malaria, GAVI)?

10 10 Health Sector Reforms Introduced in the 90s in response to worsening situation Introduced in the 90s in response to worsening situation Financial sustainability is a key component of the reforms Financial sustainability is a key component of the reforms Cost Sharing: Cost Sharing:  Generate Revenue  Improve Quality of Care  Enhance Equity  Reduce frivolous consumption

11 11 Who pays for health care in Tz (2005/6 figures)? Donor funding - grants/loans - direct or through SWAp/ GBS, 45% General tax revenue -28% - relatively progressive Out-of-pocket payments (OOPs direct payments to health care providers - 23% - very regressive Health insurance contributions - less than 10% of the population - mix Government provides a basic package of public preventive health services for ALL; minimal financial protection for the most vulnerable Source: SHIELD Project (IHI 2010), quoting Tanzania National Health Accounts 2005/06,

12 12 How many people are covered by HI in Tanzania? 9% in 2008 (SHIELD data) 9% in 2008 (SHIELD data) 13% in 2011 : NHIF (5.8%), CHF (6.6%), other schemes (1%) (NHIF data) 13% in 2011 : NHIF (5.8%), CHF (6.6%), other schemes (1%) (NHIF data) Intention to increase HI coverage to 45% by 2015 Intention to increase HI coverage to 45% by 2015 Source: Borghi j and Joachim A Who is covered by health insurance schemes and which services are used in Tanzania? SHIELD Project. IHI, Tanzania. SHIELD website:

13 13 HI coverage is highest among the better-off working in the formal sector …. In 2008, 12% of the richest groups were insured compared to 4% of the poorest groups In 2008, 12% of the richest groups were insured compared to 4% of the poorest groups Better off: mainly NHIF, some private and CHF Better off: mainly NHIF, some private and CHF Poorest: all CHF Poorest: all CHF

14 14 The poor pay a higher proportion of their income than the rich. Contributions to the NHIF are the most progressive, but only constitute a small amount of total funding (3%) & benefit those who contribute (generally better off, small proportion of the population). Tax funding is the second most progressive source of financing, benefits may be enjoyed by everyone (44%). Out-of-pocket payments represent the largest component of household contributions to health care financing, highly regressive (53%) Contributions to CHF are minimal (0%), regressive, majority of members are poor, flat rate IHI Who Pays for Health Care in Tanzania. SHIELD Project IHI Who Pays for Health Care in Tanzania. SHIELD Project HBS data 2000/01

15 15 But the rich benefit more than the poor…….. The poorest 20% receive less benefit than they need. Benefits from outpatient and inpatient care in public hospitals, and private facilities are pro-rich. Benefits from faith-based facilities are generally evenly distributed Source: IHI Who benefits from health care. SHIELD Project).

16 16 The poor consume less health care, in spite of greater need Compared to poorest quintile, the top quintile are: 3.4 times more likely to use modern contraception 3.4 times more likely to use modern contraception 2.8 times more likely to have skilled attendance at delivery 2.8 times more likely to have skilled attendance at delivery 8.7 times more likely to have a C-Section 8.7 times more likely to have a C-Section 7 times less likely to give birth at home AND have no post-natal care 7 times less likely to give birth at home AND have no post-natal care 40% more likely to have measles vaccination 40% more likely to have measles vaccination 40% more likely to receive treatment for fever at a health facility 40% more likely to receive treatment for fever at a health facility 20% more likely to receive any ORS for diarrhoea 20% more likely to receive any ORS for diarrhoea 14 times more likely to have slept under an ITN the previous night 14 times more likely to have slept under an ITN the previous night Source: Paul Smithson Fair’s Fair. Health Inequalities and Health Equity in Tanzania. Prepared for Women’s Dignity Project. IHI, Tanzania.

17 17 Barriers to effective access by the very poor Real costs of treatment (out of pocket): Real costs of treatment (out of pocket):  Drugs often greatest cost, than transport  ‘Unofficial’ or ‘under-the-counter’ fees Inflexible modes of payment Inflexible modes of payment Ineffective exemption system for those too poor to pay – exclusionary Ineffective exemption system for those too poor to pay – exclusionary Indirect costs (productive time lost) Indirect costs (productive time lost)  Often greater than direct costs  Greater burden on women Source: Mamdani M & Bangser M Poor People’s Experiences of Health Services in Tanzania. A Literature Review.

18 18 Ability and Willingness to Pay (WTP) – some estimates ~75% of respondents - “people’s ability to pay for health services” has deteriorated during the last five years. (PSSS 2003) ~75% of respondents - “people’s ability to pay for health services” has deteriorated during the last five years. (PSSS 2003) ~40% of respondents - know people who have been refused treatment because of inability to pay; over ~25% know “a lot of people”. (PSSS 2003) ~40% of respondents - know people who have been refused treatment because of inability to pay; over ~25% know “a lot of people”. (PSSS 2003) Cost of treatment reason given by ~53% of respondents as to why they did not seek care when they were last sick… (PSSS)…even Tshs 500/- fee for consultation is beyond the meager means of people, especially for women and children (TzPPA 2003) Cost of treatment reason given by ~53% of respondents as to why they did not seek care when they were last sick… (PSSS)…even Tshs 500/- fee for consultation is beyond the meager means of people, especially for women and children (TzPPA 2003)

19 19 Ability ….. (cont) 30-40% of Lindi Rural District are classified as “poor”. Food accounts for 70% of poor households’. After minimum non-food expenditure (school, health, taxes etc.), poor households have only 1% of income flexible = 1,600 Tshs per family per year. Fee range is Tshs, but community willingness and ability to pay is low; nearly a third of families reported that they had been unable to pay for care in the most recent episode. SC The Unbearable Cost of Illness. Tanzania: SC.

20 20 Ability …… (SC study continued) Ability to pay is seasonal – better at harvest time, decreases in dry season Ability to pay is seasonal – better at harvest time, decreases in dry season For acute illness, 27% resorted to self medication For acute illness, 27% resorted to self medication For chronic illness, 54% reported taking no action mainly because of lack of money. For chronic illness, 54% reported taking no action mainly because of lack of money.

21 21 What are the real costs of treatment? Evidence from TzPPA (2003): Official fees can be 35% of the total costs [paid at the facility level]; unofficial fees (hospital referral, ANC card, syringe, gloves, ‘thank you for staff’, drugs etc) can constitute 65% of the total costs (based on available figures). Informal ‘under the table’ payment from patients: widespread across many countries and a heavy burden to the poor (CGD 2006)

22 22 SC study(cont).…Most significant costs Acute illness:Transport, laboratory tests and drugs. Acute illness:Transport, laboratory tests and drugs. Chronic illness:Traditional healers, transport and drugs. Chronic illness:Traditional healers, transport and drugs. Admission :Food and accommodation Admission :Food and accommodation

23 23 Coping Mechanisms …and further impoverishment Delayed and inadequate treatment, or none at all Delayed and inadequate treatment, or none at all Sale of critical assets (their land, animals, crops, labour…) Sale of critical assets (their land, animals, crops, labour…) Reduced food intake Reduced food intake Take children out of school Take children out of school Child Labour Child Labour Borrow money Borrow money In the absence of safety nets….

24 24 Exemptions / Waivers (e/w) Exemptions: cost-sharing should not apply to children under five, MCH services (including immunizations), TB, leprosy, paralysis, typhoid, cancer, AIDS and epidemics. Waivers: free services for the poorest of the poor.

25 25 Are exemptions/waivers effective? “…a functional exemption and waiver system is actually non-existent putting vulnerable and poor people at risk by practically denying them access to public health services.” Laterveer et al 2005 SC 2005:  Lack of information and understanding about the e/w among households and health workers.  Children under 5 – only 20% were exempted for admissions; 49% for acute cases (at hospital level?)  Poor – only 50% were exempted from fees for acute illness  Better-off benefiting more than the poor on exemptions for admissions (23% vs. 12%)

26 26 Some issues with e/w What do e/w cover? Who are the very poor? The vulnerable? Who decides? Are people aware of their rights? What governance and accountability mechanisms have been put in place? What incentives do facilities have to grant e/w?

27 27 Why should the poor benefit less? A “chain of health deprivation” Perception of health status & need for care (norms, beliefs, knowledge) Perception of health status & need for care (norms, beliefs, knowledge) Propensity to seek (formal) care when ill (knowledge of danger signs, expectations & experience of health care) Propensity to seek (formal) care when ill (knowledge of danger signs, expectations & experience of health care) Able to overcome barriers to access (distance, cost (real and indirect), socio-cultural) Able to overcome barriers to access (distance, cost (real and indirect), socio-cultural) Actually receive quality care Actually receive quality care Willing & able to comply with treatment Willing & able to comply with treatment

28 28 The poor are… Less likely to perceive illness or “need” in the first place Less likely to perceive illness or “need” in the first place Less likely to seek treatment when ill Less likely to seek treatment when ill Less likely to use formal providers Less likely to use formal providers More affected by cost barriers More affected by cost barriers More affected by distance barriers More affected by distance barriers Also affected by social barriers Also affected by social barriers Less likely to obtain quality care even if they attend Less likely to obtain quality care even if they attend

29 29 Challenges facing the health system Underskilled & de-motivated health staff Underskilled & de-motivated health staff Weak management systems Weak management systems Poor quality of care Poor quality of care Inadequate information to health consumers Inadequate information to health consumers Resource constrained Resource constrained Growing burden…..(CDs + NCDs) Growing burden…..(CDs + NCDs) Poor access by the very poor to health care, etc Poor access by the very poor to health care, etc

30 30 HR - many needier and poorer Tanzanians are underserved compared to the better off Highly uneven geographical HR distribution and gap has been widening: Highly uneven geographical HR distribution and gap has been widening:  In 2007/08: the best served region had twice the number of health workers per 10,000 persons than the worst served region Areas chronically under funded and with lowest staffing allocations have the highest rates of poverty Areas chronically under funded and with lowest staffing allocations have the highest rates of poverty  Per capita health staffing budget in 2008/9: Tshs 1,400 - Tshs 14,000 across LGAs Source: GBS Equity and Efficiency in Service Delivery: Human Resources. Background Analytical Note for the Annual Review of GBS 2008, Tanzania.

31 31 Human Resource…… An absolute shortage of skilled workers Difficulties in attracting and retaining workers to underseved areas + continued recruitment and transfers to better served districts High absenteeism Poor productivity of existing staff 2007/08: MoHSW (Tz) recruited 3,645 workers, only 2,533 actually took up positions; 122 health workers were sent to Rukwa but only 31 reported, leaving 8 facilities un- operational due to staff shortages

32 32 High absenteeism, low productivity, leakages ….chronic in developing countries CGD 2006: Uganda Uganda  only 56% of facility staff existed in district records (ghost workers);  average leakage rate for drugs in public rural facilities was some 73%, ranging from 40-94% Nigeria Nigeria  42% of staff had not been paid their salaries for 6 months in the past year;  25% of health facilities had half the minimum pkg of equipment; 40% had less than a quarter of what was needed.

33 33 LGA: insufficient funding to deliver quality health services….. DxD : LGA responsible for delivery of quality health services DxD : LGA responsible for delivery of quality health services LG Budget: formula based recurrent block grants ({PE}, OC) + development budget LG Budget: formula based recurrent block grants ({PE}, OC) + development budget 2008/9: development (28%), OC (14%), PE (58%) 2008/9: development (28%), OC (14%), PE (58%) Council Plans (basis of planning - HMIS? delink of planning and budgeting….) Council Plans (basis of planning - HMIS? delink of planning and budgeting….) Teachers and health workers are the largest items of expenditure in LG budgets: approx 50% of all financial resources used at LG level Teachers and health workers are the largest items of expenditure in LG budgets: approx 50% of all financial resources used at LG level

34 34 Public Expenditure Tracking…. ……in Ghana leakage was 70% of total transfers; it was 40% in Tanzania (results in inadequate funding for non-salary spending and patients end up “contributing) (CGD 2006) Role of complexity of parallel financing mechanisms to the district, difficulties in accessing resources and strategic planning…….harmonisation & reform systems?

35 35 Health System Accountability in Tanzania Health Facility Governing Committees (HFGCs) introduced at all levels of the health system as a mechanism for improving accountability between health care providers and communities. Responsible for: Health Facility Governing Committees (HFGCs) introduced at all levels of the health system as a mechanism for improving accountability between health care providers and communities. Responsible for:  Community participation in health system  Improving quality of care  Ensuring effective exemptions  Mobilising resources from communities (eg CHF)

36 36 Rapid appraisal findings related to‘community voice’ within HFGCs HFGCs largely reflect the interests of providers rather than communities HFGC needed local government approval and support to access community members. HFGC agenda had to be fitted into a broader village meeting agenda. Communities were generally wary of the HFGC due to a broader distrust of government structures and a distrust of providers which also extended to the HFGC.

37 37 Towards strengthening the system ….(CGD 2006) Better management: adequate incentives for health professionals (supervision, enabling environment, PBF) Better management: adequate incentives for health professionals (supervision, enabling environment, PBF) Improved logistics and information systems: drug procurement reform, insitutional incentives e.g. hire and fire staff; HR database - matching staff and wage payments, eliminate abuses Improved logistics and information systems: drug procurement reform, insitutional incentives e.g. hire and fire staff; HR database - matching staff and wage payments, eliminate abuses Strengthened accountability: oversight and enforcement, health provider audits, community oversight, patient satisfaction surveys, citizens access to information on resource flows and roles and responsibilities, citizen report cards Strengthened accountability: oversight and enforcement, health provider audits, community oversight, patient satisfaction surveys, citizens access to information on resource flows and roles and responsibilities, citizen report cards

38 38 Tanzania is committed…. Mkukuta (the National Strategy for Growth and Poverty Reduction) seeks to: “Improve quality of life and social well- being, with particular focus on the poorest and most vulnerable groups” and…“Reduce inequalities across geographic, income, age, gender and other groups”

39 39 But there are huge challenges….. Significant gains in child survival risk being undermined by pervasive poverty, especially in rural areas: Significant gains in child survival risk being undermined by pervasive poverty, especially in rural areas:  34% of households living below US$1/day (HBS 2007)  Dependent on aid - about 40% of national budget in the past few years Disparities in child survival persist - between districts and regions, urban vs rural, and by wealth status. Disparities in child survival persist - between districts and regions, urban vs rural, and by wealth status. Those living in rural areas and those in poverty remain disadvantaged both in terms of service uptake and outcomes. Those living in rural areas and those in poverty remain disadvantaged both in terms of service uptake and outcomes. System -cope with continuing high burdens of communicable diseases and growing NCDs System -cope with continuing high burdens of communicable diseases and growing NCDs

40 40 Key financing issues Commitment to gradually moving away from OOP payments Effectively identifying and protecting the vulnerable Potential of scaling up range of CBHIs…common bond concept? Promote cross-subsidies in overall health system:   Improved tax funding levels   Reduce fragmentation of risk pools   Extension to non-formal sector from outset Equitable allocation of tax (and donor) funds according to need


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