1. PEER LEARNING DISTRICTS INITIATIVE REPORT ON INITIAL ASSESSMENT OF MANAGEMENT AND DELIVERY OF HEALTH SERVICES Presentation to DPG-Health and SWAp-TWG1 By: WHO Country Office – Tanzania F. Njau

2. Outline 1.Background 2.Objectives 3.Methodology 4.Findings 5.Immediate Needs

3. BACKGROUND Recommendation from JAHSR 2011 to strengthen capacity of ‘peer learning districts’ 17 good performing districts according to MOH criteria: – Kibaha, Kilosa, Bahi, Iramba, Singida, Magu, Serengeti, Kasulu, Nzega, Sumbawanga, Mbozi, Rungwe, Kilolo, Mbinga, Mtwara, Nachingwea, & Meru, (North “A”) Launching of initiative in Dodoma 11-12 September 2013 Initial assessment visits conducted to all 17 districts between January – May 2013

4. OBJECTIVES Overall Objective: To gather baseline information in preparation for provision of support to the districts to strengthen health services with specific focus on management and service delivery Specific objectives: – To advocate to the regions and districts authorities on the concept of sixteen model/peer learning districts. – To assist the districts identify immediate needs that will contribute towards improvement of the health services delivery – To support Council Health Management Teams to process and manage health information system – To collect baseline information on the performance of the indicators towards agreed targetstargets

5. METHODOLOGY-1 Visiting Teams composition – Staff from PMORALG, MOHSW, RHMT, CHMT & WHO Initial discussion meetings with regional and district authorities and health teams: ( RAS, RMO, RHMT, DED, CHMT) Review of records at regional & district level (plans, reports) Health facility visits (District Hospital & selected Health Centres & Dispensaries)

6. METHODOLOGY - 2 Use of the same MOHSW supervision checklist Debriefing meetings and development of recommendations with CHMT, DED, RMO and RAS Report writing – 18 separate district reports (one from Zanzibar) – One consolidated report to cover salient issues in the districts

7. Findings: Strengths & Lessons (1) Presence of DHBs & CHMTs noted in all districts with varying functionality (quality of members, regularity of meeting & evident problem solving) Strong working relationship between CHMTs with the DEDs is key for improved health services: – Planning and reporting (Involvement of DPLOs & Accountants) – Filling resource gaps (finance, transport etc) RHMT support to CHMT in-terms of supervision visits and allocation of Patrons/Matrons is associated with better CHMT performance

8. Findings: Strengths & Lessons (2) All districts using PlanRep tool for planning and reporting All district have supervision plans with timetables, checklists and post-supervision notes – quality needs improvement. Some districts have medicines and supplies all the time but others have challenges especially ACTs, mRDTs, HIV test kits etc CHWs, present in each village of districts visited and are used to support the services

9. Findings: Challenges (1) Inadequate skills in planning and reporting – Less than half of CHMT members can use PlanRep Tool – All CHMTs not up-to-date with current version of HMIS tools – Local data analysis and use not optimal Inadequate Quality Supportive supervision – Composition of supervision teams, Use of checklists, Active time spent at HF, Non-focus on problem solving – Poor condition of vehicles for supervision, – Community action/involvement not checked during supervision Poor state of infrastructure and utilities – Dilapidated HF buildings, Inadequate space, Lacking power and water (noted some are adopting solar power) – Shortage of staff houses in the rural settings negatively affect performance of the health services provided – Poor waste management (lack/poor quality incinerators)

10. Findings: Challenges (2) Financing problems Low budget coverage (most districts receiving < 60%) Late release of HBF and other funds Poor uptake and management of CHF, NHIF, Cost-sharing (some districts centralizing of funds at LGAs) Some Councils not contributing from own revenue HR Shortage Districts operating with average 40-50% manning levels About 70% of rural HF staff are ‘unskilled’ Shortage of essential medicines, equipment and supplies Skills in supply chain management In some cases beyond district control

11. Findings: Challenges (3) Coordination of supporting partners by regions and districts is weak Community Action CHWs programmes present in all districts BUT improvement needed on their roles and remuneration Need for revival and functioning of PHC Committees at all levels (details in the main reports and up-coming summary )

12. Immediate Needs Coordination of partners for the purpose of planning and harmonization of the activities for more effective and efficient returns to investments to ensure value for money and reduce transaction costs Capacity building of teams and management in planning and reporting including management of the health services Supportive supervision in cascade to ensure the less qualified staff in the system are mentored for the work they are doing to provide correct diagnosis and treatment

13. End Notes (reference) JAHSR 2011 milestones and key actions Concept note on SDHS-Project Launching report of the concept Dodoma Sept/2012 A list of Matrons and Patrons available Format for field visits reporting available List of all the districts which include regions and zones available Reports of the field visits already undertaken; 18 peer learning districts Summary of the 18 district reports including Zanzibar Annex 7 indicators matrix is consolidated to 17 districts in the mainland and one from Zanzibar Unguja North “A” as a base line information for future performance monitoring