1. Donors and the political economy of health sector reform in Tanzania A policy analysis perspective Aziza Mwisongo NIMR, 2008

2. Introduction Consultancy for Irish Aid carried out in Tanzania and Uganda Objective: to understand the political-economy of health sector reforms with a view of identifying constrains and opportunities facing donors in supporting evidenced-informed policy change and aid modalities Mainly done through interviews and group discussions with a range of stakeholders and documentary review Carried out collaboratively by ODI in UK and NIMR in 2006

3. Presentation outline Health reform challenges in Tanzania Dimensions of stakeholders political Feasibility of a proactive political – economy approach to informing policy dialogue and actions

4. Health reform challenges in Tanzania The country context : Poverty Reduction Strategy Paper, Health Sector Development Strategy, HSSP, political system is hybrid of legal-Rational and patrimonial,UK inherited bureaucratic civil service system, Tanzanian Assistance Strategy, political – economy not documented Progress in the health sector: some progress in infant and child mortality, increased use of bednets, lowered incidence of malaria BUT low family planning acceptor rate, inadequate use of skilled birth attendants, low facility births, no progress in MMR, good prioritization and managing resources BUT no progress in fostering private –public partnership( HRH crisis )

5. Continued…. Prioritization and coordination with constrained resources: 1) per capita spending on health non sufficient for HSSP, 2) health spending highly donor dependent, actual prioritization influenced by budgetary processes and negotiations ( GHI), 3) lack of data on LGA spending, more weight on political decisions ( presidents decision) Existence of SWAp related problems : rigid funding to districts, cuts in OC, extensive system of allowances as salary top ups, ARV budget on expense of basic immunization in MTEF, separate basket accounting, high central expenditure compared to districts, high off budget, GHI problems: ignore official sector policy, strain in govt leadership, balance accorded to few specific diseases, parallel systems, costly commodities, lack of transparency, questionable sustainability Constraints to improving efficiency and efectiveness of services: bifurcation of responsibility by MOHSW and LGA and reemergence of projects rendering more power on managers

6. Dimensions of stakeholders political Powerful interactive set of political economy constraints block reform processes; High politics of health sector policy: populist and patrimonial initiatives, pet projects implementation through supplementary budgets, using high level contacts to introduce expensive initiatives( ARVs), policy making by health policy cabal The global and local aid architecture: several funding routes fragments balance of power, finances confers some influence but unpredictable, donors use of technical expertise in SWAP committees to influence policies BUT unpredictable, use of allowances to attract officials but deleterious, GHI and PEPFAR shifting balance of stakeholders interest in SWAp, Donors disagreements, soft conditionalities off tracking key issues, poor donor actions against poor government performance, fear of challenging govt,

7. Continued…. The organization of interest and advocacy: MOF silent opposition to some key health decisions, e.g. HRH issues, weak professional group activism, restrictions to collective bargaining, NGOs limited access and fear of being in odds with govt, NGOs advocacy for advocacy is limited, LGA limited involvement in policy discussions, middle class population is not affected by the problems so lack of questioning,

8. Feasibility of a proactive political – economy approach to informing policy dialogue and actions Constrains : limited use of political –economy, translation of Paris declaration by accepting government inadequacies or pulling out /cutbacks, donors indifferences on how hard to push, lack of use of opportunities on similar stands, limited networking, health advisors are technical rather than brokers, undue caution of some multilateral to work with CSO, culture of mistrust of Govt and NGOs, leadership and capacity problems, unsupportive of critical thinkers

9. Continued… Opportunities: engage MOF, using evidence from PER and NHA for dialoguing and alliances, using JAR for retrospective policy analysis, empowering NGOs to influence priorities, SWAp committees to look and discuss political –economy issues, mobilize high profile support ( although could be knee jerk) but also use to create synergies