1. 1 SECTOR WIDE APPRO ACHES IN TANZANIA THE CURRENT STATUS, CHALLENGES AND SUCCESS STORIES BY Dr. Faustin Njau Head, Health Sector Reform Development Program MOH Tanzania.

2. 2 Characteristics of Health Sector Wide Approaches Significant funding for the sector supports as a single sector policy expenditure programme Significant funding for the sector supports as a single sector policy expenditure programme The government provides leader ship (Government in Drivers seat !!) The government provides leader ship (Government in Drivers seat !!) Adopting common approaches across the sector and progressing towards relying on government procedures to: Adopting common approaches across the sector and progressing towards relying on government procedures to: Disburse and account for funds Disburse and account for funds Procure goods, services Procure goods, services Monitor progress made to Improve peoples health Monitor progress made to Improve peoples health

3. 3 The government objectives under swaps Change in the way the sector is managed, financed and strengthen dialogue mechanisms or structures Change in the way the sector is managed, financed and strengthen dialogue mechanisms or structures Shift roles and responsibilities & decentralize to lower levels Shift roles and responsibilities & decentralize to lower levels Measures that will ensure AVAILABILITY, accessibility, quality, affordability, and equity in provision of health care Measures that will ensure AVAILABILITY, accessibility, quality, affordability, and equity in provision of health care Application of effective strategies for community involvement and empowerment Application of effective strategies for community involvement and empowerment

4. 4 What does health sector dialogue look like? Sector reviews Sector reviews Technical Committee of the SWAp Technical Committee of the SWAp(TC-SWAp) Technical Working Groups (TWGs) Technical Working Groups (TWGs)

5. 5 Dialogue structure Health SWAPs Sector Review 9 so far, going to the 10 th a (Decade of SWAps in Tanzania) 2009 Sector Review 9 so far, going to the 10 th a (Decade of SWAps in Tanzania) 2009 Technical Committee of the SWAp (TC- SWAp) every 2 months but more on demand!!! Technical Committee of the SWAp (TC- SWAp) every 2 months but more on demand!!! Technical Working Groups (TWGs) on thematic areas-too many and some have no value addition, they do not even meet. Technical Working Groups (TWGs) on thematic areas-too many and some have no value addition, they do not even meet. Other meetings/ ‘dialogue Other meetings/ ‘dialogue

6. 6 Other meetings/ ‘dialogue’ DP Troika joins monthly senior MOHSW management meeting DP Troika joins monthly senior MOHSW management meeting Basket Financing Committee – discusses issues relating to this financing modality only. Basket Financing Committee – discusses issues relating to this financing modality only. DPG Health meets on the first Wednesday of every month DPG Health meets on the first Wednesday of every month Financing committee is more powerful than the technical arm. “Save the money or lives is an issue if the MDGs have to be reached.”

7. 7 Swaps 18 years bench marks1991-2009 1984 Economic Recovery Programme (ERP) resulting in the liberalization of the economy 1984 Economic Recovery Programme (ERP) resulting in the liberalization of the economy 1991 Pharmacy Board strengthened 1991 Pharmacy Board strengthened 1993 user charges introduced at National health facility level 1993 user charges introduced at National health facility level 1994 user charges extended to cover regional and district hospitals 1994 user charges extended to cover regional and district hospitals 1995 introduction of user charges to health centres and dispensaries shelved 1995 introduction of user charges to health centres and dispensaries shelved

8. 8 Cont -2 Swaps 18 years bench marks 1991-2009 1993 health sector performance reviewed 1993 health sector performance reviewed 1994 Health Reforms Proposals document prepared 1994 Health Reforms Proposals document prepared 1995 -1996 draft POW and POA prepared 1995 -1996 draft POW and POA prepared January 1998 Joint review of Health sector reforms. 9 reviews to date. January 1998 Joint review of Health sector reforms. 9 reviews to date.

9. 9 Cont -3 Swaps 18 years bench marks1991- 2009 May 1998 Statement of Intent ( majority of Health partners and the GOT ) agree to apply SWAPS during implementation of health sector reforms May 1998 Statement of Intent ( majority of Health partners and the GOT ) agree to apply SWAPS during implementation of health sector reforms March 1999 GOT and partners endorse the MOH three year plan ( July 1999 to June 2002) and the annual PPOA March 1999 GOT and partners endorse the MOH three year plan ( July 1999 to June 2002) and the annual PPOA July 1999 to date SWAps application introduced in phases July 1999 to date SWAps application introduced in phases We are in the HSSP 3 effective from 1 st of July 2009. We are in the HSSP 3 effective from 1 st of July 2009.

10. 10 Phases of HSR 1.Conceptualization and studies 1.Conceptualization and studies 2.Proposals to the government 2.Proposals to the government 3.Pre-implementation phase and managing change 3.Pre-implementation phase and managing change  Systems development  Strategies and tools  Setting up committees and bodies  Technical guidelines and protocols  Legal frame work and structures  Setting up the Health Sector Reform Secretariat

11. 11 Cont –> 2 Phases of HSR 4.Implementation 4.Implementation phasing Districts->3 phasing Districts->3 MOUs MOUs Code of conduct Code of conduct Studies Studies Adjustments Adjustments We are now at this 4 th phase towards phase of consoliation below. Completion of Reforms and consolidation phase is an anticipation

12. 12 Health sector strategies are 9 but HSSP3 ARE 11. 6.1 Strategy 1-_District health services 6.1 Strategy 1-_District health services 6.2 Strategy 2 Secondary and Tertiary hospital services 6.2 Strategy 2 Secondary and Tertiary hospital services 6.3 Strategy 3 Role of the Central Ministry of Health 6.3 Strategy 3 Role of the Central Ministry of Health 6.4 Strategy 4-Human Resources Development 6.4 Strategy 4-Human Resources Development

13. 13 Cont- 2 Health sector strategies are now 9 but the HSSP 3 are 11. 6.5 Strategy 5 Health care Financing 6.5 Strategy 5 Health care Financing 6.6 Strategy 6 Public Private Partnership 6.6 Strategy 6 Public Private Partnership 6.7 Strategy 7 Maternal, New born and child health 6.7 Strategy 7 Maternal, New born and child health 6.8 Strategy 8- Diseases Specific Programs 6.8 Strategy 8- Diseases Specific Programs 6.9 Emergency Preparedness 6.9 Emergency Preparedness 6.10 Social Welfare and Social Protection 6.10 Social Welfare and Social Protection 6.11 Monitoring Evaluation and Research 6.11 Monitoring Evaluation and Research

14. 14 Notable Achievements a new resource allocation formula that takes into account population 70%, poverty count 10%, district vehicle route 10% and under five mortality 10% was developed and is being used for both Basket and Health Block grants since 2004 a new resource allocation formula that takes into account population 70%, poverty count 10%, district vehicle route 10% and under five mortality 10% was developed and is being used for both Basket and Health Block grants since 2004 Council Health Services Boards and facility committees have been established in all 132 local authorities (but weak management of the same) Council Health Services Boards and facility committees have been established in all 132 local authorities (but weak management of the same) We are in the process of establishing Community Health Fund in all the 132 Councils We are in the process of establishing Community Health Fund in all the 132 Councils

15. 15 Cont ->2 Notable Achievements Rehabilitation of health centers and dispensaries started based on joint rehabilitation manual in phases, this is giving way to LGDG Health window Rehabilitation of health centers and dispensaries started based on joint rehabilitation manual in phases, this is giving way to LGDG Health window District and Regional hospital reforms have been initiated whose aim is to strengthen hospital management, to improve quality District and Regional hospital reforms have been initiated whose aim is to strengthen hospital management, to improve quality The MOH has prepared inputs to “ Improved quality of life and social well being cluster” of the NSGRP (MKUKUTA) and we are now preparing inputs to MKUKUTA 2, (20011-2015). The MOH has prepared inputs to “ Improved quality of life and social well being cluster” of the NSGRP (MKUKUTA) and we are now preparing inputs to MKUKUTA 2, (20011-2015).

16. 16 Cont ->3 Notable Achievements Special review of the Private Public Partnership has been carried out, bottlenecks have been identified and it is expected that concrete action to address this area will be implemented. Special review of the Private Public Partnership has been carried out, bottlenecks have been identified and it is expected that concrete action to address this area will be implemented. Capacity development for Regional health teams to enable them perform their expected roles in support of CHMTs has been initiated all 21 RHMT have been trained Capacity development for Regional health teams to enable them perform their expected roles in support of CHMTs has been initiated all 21 RHMT have been trained

17. 17 Monitoring process of the sector The process is carried out through: The process is carried out through: Quarterly Progress reports Quarterly Progress reports Annual financial and technical reports Annual financial and technical reports Health Sector Performance profile Health Sector Performance profile

18. 18 Cont – 2 Monitoring process of the sector Annual Health Sector Reviews, SWAPs and BFC committee reports Annual Health Sector Reviews, SWAPs and BFC committee reports Review of comprehensive plans and monitoring indicators for progress by all local 121LGAs Review of comprehensive plans and monitoring indicators for progress by all local 121LGAs poverty monitoring system (PMS)for MKUKUTA –NSGRP. poverty monitoring system (PMS)for MKUKUTA –NSGRP.

19. 19 Sources of monitoring data HMIS (very weak as yet) HMIS (very weak as yet) Study reports commissioned each prior to the main review as part of technical review Study reports commissioned each prior to the main review as part of technical review Annual Public Expenditure reviews Annual Public Expenditure reviews Periodic health service delivery surveys and other surveys Periodic health service delivery surveys and other surveys 8, National sentinel Stations 8, National sentinel Stations

20. 20 Cont – 2 Sources of monitoring data Demographic health survey Demographic health survey National Population Census National Population Census National programme reports National programme reports Annual reports from RMOs, District Medical Officers and Reproductive and Child Health (21 Regions and 132 Districts) Annual reports from RMOs, District Medical Officers and Reproductive and Child Health (21 Regions and 132 Districts) National Poverty Monitoring System, Research and analysis. National Poverty Monitoring System, Research and analysis.

21. 21 Our Great challenges are: Our Great challenges are: (a) At national level (health systems) issues 1.HIV/AIDS Pandemic – in it is a disaster 2.Under funding of sector 3.Growing demands due to Burden of Disease – TB, Malaria, accidents and other chronic illness – Diabetes mellitus, bilharzias, onchocerciasis, etc 4.Human resources for the health care is out of balance Management component Management component Health providers in crisis Health providers in crisis

22. 22 Our Great challenges cont->2: 5. Maximization of the Private sector is at minimum level. Attempts have been made to highlight on the PPP through Joint Health Sector Reform all the years 6. Old and dilapidated Health infrastructure 7. Growing digital divide and hence knowledge gap especially on specialized professional areas 8. Multiple reforms in the government 9. Climate Change Climate change (the world is warming up) is increasing new epidemics

23. 23 Challenges, -> (b) Development Partners Coordinating partners is not an easy task Coordinating partners is not an easy task Policies not flexible when it comes to the methods of financing the sector (we feel pushed to comply with int. prescription eg Global Funds-ATM) Policies not flexible when it comes to the methods of financing the sector (we feel pushed to comply with int. prescription eg Global Funds-ATM) Incremental conditionalities continue to loom around and is personality dependent at times Incremental conditionalities continue to loom around and is personality dependent at times Parallel systems of procurement, auditing and TA is a gray zone. Parallel systems of procurement, auditing and TA is a gray zone.

24. 24 Challenges,->2 (b) Development Partners Some have specific areas of their interest and verticalize the MTEF activities and especially the commodities. Shy away from human resource issues. Some have specific areas of their interest and verticalize the MTEF activities and especially the commodities. Shy away from human resource issues. Pilots and projects will still exist and programmes are sometimes difficult to pursue in Toto Pilots and projects will still exist and programmes are sometimes difficult to pursue in Toto Verticalization can be minimized but remain a factor. Verticalization can be minimized but remain a factor. Institutional memory changes as individuals swap desks or counties. Institutional memory changes as individuals swap desks or counties. There is a need for the MoU and Code of conduct to be adhered to as a necessity There is a need for the MoU and Code of conduct to be adhered to as a necessity

25. 25 (c) Global Changes->cont Unfulfilled promises or financial commitments (global agreements)Unfulfilled promises or financial commitments (global agreements) Changing priorities at this level almost all the timesChanging priorities at this level almost all the times Too many meetings and processes without concerted actionsToo many meetings and processes without concerted actions Pressure for parallel systems especially when funds are available (too many NGOs difficult to monitor and regulate)Pressure for parallel systems especially when funds are available (too many NGOs difficult to monitor and regulate)

26. 26 ADDRESS THE CHALLEGES Identifying difficult areas and set milestones annually during reviews Identifying difficult areas and set milestones annually during reviews Mobilize more resources for health and maximize on available resources Mobilize more resources for health and maximize on available resources Enhance monitoring system for performance Enhance monitoring system for performance Capacity building for human resources on Capacity building for human resources on Management Management Service providers Service providers Numbers matter!!! Numbers matter!!!

27. 27 Cont -2 ADDRESS THE CHALLEGES Match inputs with outcomes (MKUKUTA) Match inputs with outcomes (MKUKUTA) Better coordination and collaboration with our partners, thus building trust and transparency Better coordination and collaboration with our partners, thus building trust and transparency Step up advocacy for reforms Step up advocacy for reforms Focus more on community ownership and participation (Shares holding in health services) Focus more on community ownership and participation (Shares holding in health services) Continue with Annual Technical Review and Policy Reviews to market the sector Continue with Annual Technical Review and Policy Reviews to market the sector

28. 28 POVERTY REDUCTION LINKED WITH HSSP AND MDGs (Planning ahead) It is part of NSGRP – MKUKUTA It is part of NSGRP – MKUKUTA The HSSP 2003/08 was positioned in MKUKUTA – 9 strategies and three (3) clusters, HSSP3 we have done the same MDGs 1-8 all have a bearing on health. It is not only MDGs 4,5&6. MDGs 1-8 all have a bearing on health. It is not only MDGs 4,5&6. Impact of climate change on health is not yet fully known WATCH OUT!! Impact of climate change on health is not yet fully known WATCH OUT!!

29. 29CONCLUSSION The health sector is one of the 17 reforms going on in Tanzania under the supervision of the government. The health sector is one of the 17 reforms going on in Tanzania under the supervision of the government. The sector problems are known and the solutions are also known. The sector problems are known and the solutions are also known. Resources and willingness at different levels still not in place and especially at the global level (ODA). Resources and willingness at different levels still not in place and especially at the global level (ODA). A complete paradigm shift is needed and change management mode including corporate governance. A complete paradigm shift is needed and change management mode including corporate governance.

30. 30 Cont -2 conclusion But these are the variables which are not easy to be accepted by all the actors within the same time frame. But these are the variables which are not easy to be accepted by all the actors within the same time frame. Opportunities have to be realized and made advantages of. Opportunities have to be realized and made advantages of. The political dimension has to be brought afore, and advocated at different levels. The political dimension has to be brought afore, and advocated at different levels. Lobbying may be a necessity and building alliances with those who genuinely support the health sector. Lobbying may be a necessity and building alliances with those who genuinely support the health sector.

31. 31 THANK YOU FOR LISTENING