1. 1 Assessment of health progress and performance, mainland Tanzania: Analytical report Introduction and outline Dar es Salaam, 4 February 2013

2. Objectives of the analytical report To produce a comprehensive assessment of health progress and performance in mainland Tanzania in order to inform the MTR of HSSP III and other strategies/plans as relevant Other strategies / plans may include: –National Roadmap strategic plan to accelerate reduction of maternal, newborn and child deaths 2008-2015 –Primary health services development programme 2007-2017 (MMAM) –MDG progress reviews, Global Fund and other development partner related monitoring –National strategies: Vision 2025, MKUKUTA To strengthen capacity for health progress and performance assessment 2

3. Indicators & analysis Focus on the key indicators and targets of HSSP III (32) –Results framework: inputs-outputs-outcomes-impact –Consideration of "current" situation and 2015 targets Also take into account additional indicators in the same programme areas if these can help assess progress or are included in related strategies/plans –E.g. life expectancy (Vision 2025), RMNCH indicators Emphasis on disaggregation (equity) if possible, especially subnational (mostly region if possible district) Take into account any contextual factors, such as economic and social indicators at subnational and national level 3

4. Inputs & processesOutputsOutcomesImpact 32 Indicators for HSSP III 2009-2015, MOHSW, Tanzania Service access EMOC facilities Medicines and medical products stockouts in health facilities Quality Malaria lab confirmation TB treatment success Leprosy treatment success Immunization Measles, DPT/penta3 Vitamin A in children Antenatal and delivery care ANC At least 4 times ANC started before 16 wks TT2 Skilled birth attendance Contraceptive prevalence HIV ART for PMTCT ART coverage Malaria IPT2 ITN among children and pregnant women Cholera CFR among treated Hypertension prevalence 25- 64 Neonatal, infant and child mortality rates Maternal mortality ratio Total fertility rate HIV prevalence 15-24 years Pregnant women 15- 24 Malaria parasitemia in children TB notification rate Leprosy notification rate Cholera incidence Orphanhood prevalence Financing THE per capita Enrollment in CHF Human resources Density by region: MO and AMO; nurse midwives; pharmacists; health officers; lab Training institutions with accreditation Child growth: severe underweight, severe stunting

5. Cross cutting issues in HSSP III 1.Equity: geographic, vulnerable groups 2.Gender sensitivity 3.Quality of services, management etc. 4.Community ownership, including healthy life styles, care in the family, health service interface 5.Coherence in health services planning and implementation 6.Complementarity in governance: management, PPP Equity analyses Improved service coverage Improved intervention quality, uptake and impact

6. Implementation areas in HSSP III 1.District health services 2.Referral hospital services 3.Central level support 4.Human resources 5.Health care financing 6.Public private partnership 7.Maternal newborn and child health 8.Disease control: HIV/AIDS, TB & leprosy, NTD and epidemic prone diseases, NCD, environmental health 9.Emergency preparedness 10.Social welfare 11.M&E 12.Other important issues: capital investments, ICT 156 indicators, mostly for management purposes, limited use in this report Some could be included in the analytical progress report 156 indicators, mostly for management purposes, limited use in this report Some could be included in the analytical progress report

7. Main data sources Input indicators Financial tracking; resources, expenditure –National Health Accounts: 2005, latest –Public Expenditure Reviews –Other sources Health workforce –HR data bases: quality, other sources than MoH –Recent special studies Policy changes –All relevant policies and policy changes since 2009 from qualitative review

8. Main data sources Output indicators Availability and readiness of health services: tracer medicines and medical products –National data bases (by regional and district): facilities, specific type of services (ARV therapy, PMTCT, EMOC) –Health facility data (HMIS) –Facility surveys 2008/09: 15 districts, NIMR & WHO 2012: 27 districts, Ifakara Quality of services –Health facility data (HMIS): Lab confirmation rates for malaria TB treatment outcome (success rate) Research studies Outpatient utilization rates –HMIS, economic survey

9. Main data sources Outcome indicators Coverage of interventions (with equity) –HMIS: ANC, PMTCT, postnatal care, delivery, CS rates, immunization, vitamin A, ART coverage, TB treatment and notification rates, FP –TDHS 2004/05 and 2010/11 –THMIS 2011 –National panel survey –Research studies Risk factors –TDHS 2004/05 and 2010/11 –STEPS 2012 if available –Research studies

10. Main data sources Impact indicators Mortality and fertility –TDHS 2004/05 and 2010/11 –Census –HMIS (causes of death, case fatality rates) –Health and Demographic Surveillance Studies (Ifakara, NIMR) Morbidity –HMIS –Surveillance system (HIV, cholera) –Surveys: THMIS Financial protection

11. Analytical approaches What can be done? Data quality assessment: completeness accuracy Target and trend analysis: rate of progress Putting data from different sources together (to obtain best estimate and assess data quality) Equity analysis: geographic, individual characteristics Stepwise analysis using the results framework Efficiency analysis: comparing results with inputs Estimates: use of statistical modelling Comparative analysis: internal and external Lives saved computation (LiST)

12. End 12

13. Putting data from different sources together Health facility and survey data available for the same indicators Coverage of interventions: immunization, ANC, SBA/institutional delivery, etc. Assess biases, make adjustments 13

14. Comparison Delivery rates: HMIS fairly consistent with DHS 2010 HMIS is higher Rukwa Kigoma TDHS 2010 is higher

15. Disaggregation (equity) Health facility reports –age –subnational data: district Health surveys –sex, age –Education, wealth quintile –Place of residence: urban rural, province/region 15

16. An example from a survey 2012 Countdown Report

17. 17 Stepwise analysis

18. 18 Efficiency – comparing inputs and results Underperformers – higher mortality than expected on the basis of money for health Good performers

19. Regional performance Coverage of deliveries by health worker density* Better than average performers Poorer than average performers * Dar es Salaam and Kilimanjaro have more than one-third of health workers in Mainland and are excluded Pwani Iringa Morogoro Tanga Arusha Mwanza Mbeya Shinyanga

20. Use of estimates An estimate is based on statistical modeling with transparent assumptions to obtain the best picture of the real situation Done for many indicators –Mortality; child, maternal, adult, life expectancy, causes of death –Coverage: immunization, water and sanitation Often done by global agencies to obtain comparable data –Same year, same method for all countries 20

21. Child mortality – IGME estimates www.childmortality.org 21

22. 22 Benchmarking Comparison –Who to compare with: Regional average / peer countries –How: average, median or best performers, compared to international targets (e.g. MDG, Abuja 15%) Statistical measures –Absolute or relative progress –Ranking (e.g. 14th out 42 countries) –Percentile (e.g. 67th percentile out of 42 countries) –Position compared to country or regional mean/median Benchmarking –Comparison with top performers (e.g. best 10%)

23. 23 Performance assessment Putting it all together Identifying contextual changes –Demographic, economic, social and political factors Progress assessment –Compared to targets –Compared to peers –Putting together data from different sources Equity analysis –Trends in equity gaps by key stratifiers Efficiency analysis –Results by inputs; use of summary measures Performance = Summarizing and interpreting the results

24. How well is the analysis in the annual review report done? 1.Data quality assessment included? 2.Target and trend analysis done? 3.Stepwise systematic analysis of progress and performance? 4.Data from different sources is put together? 5.Equity receiving attention? 6.Efficiency analysis done at subnational level? 7.Comparative analysis within country done? 8.Comparative analysis with peer countries done ? 24

25. 25 Benchmarking of progress (spreadsheet) Spreadsheet - data from World Health Statistics 2010 Selected set of indicators with data over time –Total health expenditure per capita –General government expenditure on health as percent of total expenditure –DPT3 coverage –Child stunting –Child mortality (under five) rate Use different measures to examine the data and position over time How well has your country done: Subjectively interpret your country's results and draw your conclusion for your country

26. 26 Components of the progress and performance review 1.Progress: the extent to which health system goals in terms of levels of health and financial risk protection have been attained 2.Equity: the progress in term of distribution of the health system goals 3.Efficiency: the extent to which the resources used by the health system have produced the maximum possible benefit to society Performance Policies, strategies, resource allocation Context