PRIORITY SETTING PROCESS ON NUTRITION AND USE OF GUIDELINES IN RESOURCE ALLOCATION IN ARUSHA DISTRICT COUNCIL Temina Mkumbwa MPH-Executive Track 22 nd July 2014

Background In fiscal year 2010/11, only US$1.4 million was allocated for nutrition activities across all districts, this was about US$1 per child in contrast to US$6 per child set as the minimum requirement per child for nutrition activities (HKI, 2011;UNICEF, 2013) In resource constrained countries, priority setting processes determines which health care needs will be met and which ones will not in terms of funding required for implementation of health activities. In Tanzania, priority setting for health activities (nutrition included) is done during the planning and budgeting process through the Comprehensive Council Health Plan (CCHP). The CCHP Guidelines are designed to guide the allocation of resources but evidence shows that they have not been successful in ensuring adequate resources to nutrition activities and therefore there is a need to understand the process and criteria for resource allocation including the use of the guidelines.

Research Question How is the priority setting process on nutrition conducted within the Tanzanian health system compared to other preventive health activities and to what extent are the CCHP Guidelines utilized in resource allocation in Arusha District Council?

Objectives Overall: To examine the priority setting process on nutrition compared to other preventive health activities and to evaluate the use of the CCHP Guidelines in resource allocation in Arusha District Council. Specific Objectives 1. To examine the priority setting process on nutrition compared to other preventive health activities in Arusha District Council. 2. To assess the usefulness of the priority setting tools in resource allocation to nutrition compared to other preventive health activities in Arusha District Council. 3. To evaluate the use of guidelines and criteria used for allocating resources for nutrition activities compared to other preventive health activities in Arusha District Council. 4. To assess the knowledge on nutrition activities compared to other preventive health activities among the CCHP planning team members in Arusha District Council. 5. To assess the attitude on nutrition activities compared to other preventive health activities among the CCHP planning team members in Arusha District Council.

Methodology A cross sectional –exploratory qualitative study was conducted to capture and analyse the priority setting process in the context of nutrition compared to other preventive health activities/ Child Survival Interventions. (Immunization, Malaria, HIV and Family Planning) The study was conducted in Arusha District Council between May – June 2014 and involved 13 key members of the CCHP planning team. Two types of data were collected:  primary data included In-depth Interviews (IDIs)  secondary data included review of key documents, such as the CCHP Guidelines, District PlanRep tool, and districts’ health budgets from FY 2009/11 through FY 2013/14 along with annual budget expenditure reports to determine actual expenditure on nutrition. For comparison, all questions referred to nutrition, family planning, immunization, malaria and HIV. Data from IDIs were transcribed and entered into a database using the QSR NVIVO 8 software for management of files, coding and further analysis. Data was analysed using content analysis, which involved transcribing, editing, coding and categorizing information into various themes. Study Limitation: This study was conducted in one district and therefore does not provide an opportunity to assess the priority setting processes of other regions. However, it can be useful in identifying potential challenges that may exist in these regions and provide solutions for adequate resource allocation for nutrition activities.

Results - 1 Priority setting process: We found a number of shortfalls in the priority setting process, the criteria and the use of CCHP Guidelines which may have led to inefficient priority setting decisions on nutrition. This study revealed that the priority setting process is not done according to the instructions in the CCHP guidelines. As stated by a member of the CCHP planning team: “To tell you the truth, the majority of what is being said in the guidelines is not what we actually do. For example we are required to involve communities and health facilities as part of the priority setting process but we never do because of the fact that most of the time we don’t have enough time and money to do the planning” Another member stated: “To determine priorities we conduct a situation analysis which is based on HMIS data and not really the priorities identified by health facilities or communities…however the data in most cases does not come complete which affects the whole priority setting process”.

Results-2 Priority setting tools: Priority setting tools were not adequately adapted for nutrition needs which may have led to inadequate resources allocated for nutrition. Planning and budgeting tools used at district level did not have a specific area for nutrition and therefore did not allow for adequate resources to be allocated for nutrition activities. Knowledge on nutrition activities: The study revealed that knowledge on nutrition activities among the district planning team was low compared to other preventive health services. Only 1 out of 4 questions on nutrition was answered correctly by all district planning team members.

Conclusion It is evident that there are still several gaps and obstacles that need to be addressed in the health priority setting process to achieve proper support for nutrition initiatives in Tanzania.

Recommendations 1. Ensuring the PlanRep tool includes nutrition to emphasize resource allocation to nutrition. This can be done by including nutrition among the list of ten priorities. 2. Further research is needed to assess factors influencing resource allocation to help identify avenues for increasing nutrition funding allocation.

ASANTENI!