Browsing by Author "Maluka, Stephen"

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    The Accountability for Reasonableness Approach to Guide Priority Setting in Health Systems Within Limited Resources – Findings From Action Research at District Level in Kenya, Tanzania, and Zambia
    (2014-12) Byskov, Jens; Marchal, Bruno; Maluka, Stephen; Zulu, Joseph M.; Bukachi, Salome A.; Hurtig, Anna-Karin; Blystad, Astrid; Kamuzora, Peter; Michelo, Charles; Nyandieka, Lilian N.; Ndawi, Benedict; Bloch, Paul; Olsen, Øystein E.; Consortium, React
    Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT).
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    An Assessment of the Implementation of the Re-structured Community Health Fund in Gairo District in Tanzania
    (Tanzania Journal of Development Studies, 2020) Asantemungu, Raphael; Maluka, Stephen
    While the government of Tanzania has been implementing community health fund (CHF) for more than two decades, the uptake of the scheme has been persistently low due to management and performance problems. As a response, from 2011 a new initiative was adopted that changed the overall structure, management and benefit packages of the CHF. This paper assesses the implementation of the newly re- structured CHF in Gairo District in Morogoro Region. This study employed a descriptive qualitative case study design using three types of data collection techniques, namely individual interviews (n=14), focus group discussions (n=4) and document review. A thematic approach was used to analyse the data. Findings show that the re-structured CHF has improved the pooling and provider payment mechanism compared to the old CHF. Benefit packages have been expanded to include referral services up to regional level. However, stakeholders, including community members, had negative perceptions of the restructured CHF owing to high annual premium rates, low incentive to enrolment officers, weak registration network and poor quality of health care services. In order to improve CHF performance and achieve universal health coverage, the central Government needs to invest more in the improvement of the quality of health care services, particularly the availability of drugs and medical supplies. Additionally, the government should make CHF scheme compulsory to all members of the community who do not have alternative health insurance.
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    Autonomy without capacity: the role of health facility governing committees in planning and budgeting in Tanzania
    (University of Dar es Salaam, 2023-03) Maluka, Stephen; Kamuzora, Peter; Hurtig, Anna-Karin; San Sebastian, Miguel; Mtasingwa, Lilian; Kapologwe, Ntuli
    Since the inception of health-sector reforms in Tanzania in the 1990s, health planning and implementation was decentralised to the Council Health Management Teams (CHMTs) headed by the District Medical Officer (DMO). This arrangement centralised the autonomy for planning, budgeting and resource allocation at the district level with very limited autonomy and authority at the health facility and community level. Since 2017/2018, the government of Tanzania has further transferred the autonomy to plan, budget and manage financial resources to health facilities. Under the current arrangements, each health facility prepares its comprehensive annual health plan and budget, and funds for the implementation of the plans are transferred directly from the Ministry of Finance and Planning (MoFP) to health facilities; the policy known as Direct Health Facility Financing (DHFF). Each health facility is supposed to have a planning team responsible for preparing annual plans. The team is required to: (i) conduct a thorough assessment of the implementation of the previous year comprehensive health facility plans to guide preparation of subsequent annual plan; (ii) gather community opinions regarding priorities and challenges in accessing health care services to inform the planning process; (iii) conduct a robust situational analysis about the morbidity and mortality trends, underlying causes and health system bottlenecks hampering the delivery and uptake of interventions; (iv) prepare plans in accordance to existing guidelines; (v) provide feedback of the approved facility plan to Health Facility Governing Committee (HFGC), Village Development Committee (VDC) and Ward Development Committee (WDC); and (vi) ensure that the plans are responsive to local needs (facility and population). The central government issues guidelines that steer the planning process at the district and health facility levels. The CHMTs and health facilities need to abide by these guidelines when preparing their annual health plans. Similarly, the central government supplies the budget making guidelines, which stipulate the ‘budget ceilings’ that every district and health facility has to adhere to. All facility plans are at later stage consolidated into a Comprehensive Council Health Plan (CCHP) for the whole district. Similarly, the preparation of the CCHP is led by a guideline from the central government. The consolidation process is done by the CCHP planning team led by the District Medical Officers (DMOs). After endorsement at the Council level, the plan is submitted to the Regional Secretariat (RS) for assessment, approval and submission to the national level. At this level, the plan is assessed by assessors comprising members from the President’s Office-Regional Administration and Local Government (PORALG) – Health and MoH and recommended for funding.
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    Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania
    (WILLEY & Sons, 2019-01) Kuwawenaruwa, August; Remme, M; Mtei, Gemini; Makawia, Suzan; Maluka, Stephen; Kapologwe, Ntuli; Borghi, Jo
    Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in‐depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health‐governing committees.
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    Challenges to Fair Decision-Making Processes in The Context of Health Care Services: A Qualitative Assessment from Tanzania
    (2012-06) Shayo, Elizabeth; Norheim, Ole F.; Mboera, Leonard; Byskov, Jens; Maluka, Stephen; Kamuzora, Peter; Blystad, Astrid
    Fair processes in decision making need the involvement of stakeholders who can discuss issues and reach an agreement based on reasons that are justifiable and appropriate in meeting people's needs. In Tanzania, the policy of decentralization and the health sector reform place an emphasis on community participation in making decisions in health care. However, aspects that can influence an individual's opportunity to be listened to and to contribute to discussion have been researched to a very limited extent in low-income settings. The objective of this study was to explore challenges to fair decision-making processes in health care services with a special focus on the potential influence of gender, wealth, ethnicity and education. We draw on the principle of fairness as outlined in the deliberative democratic theory. The study was carried out in the Mbarali District of Tanzania. A qualitative study design was used. In-depth interviews and focus group discussion were conducted among members of the district health team, local government officials, health care providers and community members. Informal discussion on the topics was also of substantial value. The study findings indicate a substantial influence of gender, wealth, ethnicity and education on health care decision-making processes. Men, wealthy individuals, members of strong ethnic groups and highly educated individuals had greater influence. Opinions varied among the study informants as to whether such differences should be considered fair. The differences in levels of influence emerged most clearly at the community level, and were largely perceived as legitimate. Existing challenges related to individuals' influence of decision making processes in health care need to be addressed if greater participation is desired. There is a need for increased advocacy and a strengthening of responsive practices with an emphasis on the right of all individuals to participate in decision-making processes. This simultaneously implies an emphasis on assuring the distribution of information, training and education so that individuals can participate fully in informed decision making.
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    Contracting Out Non-State Providers to Provide Primary Health Care Services in Tanzania: Perceptions of Stakeholders
    (Kerman University Medical Sciences, 2018-05) Maluka, Stephen
    Background: In the attempt to move towards universal health coverage (UHC), many low- and middle-income countries (LMICs) are actively seeking to contract-out non-state providers (NSPs) to deliver health services to a specified population. Research on contracting-out has focused more on the impact of contracting-out than on the actual processes underlying the intervention and contextual factors that influence its performance. This paper reports on perceptions of stakeholders on contracting-out faith-based hospitals through service agreements (SAs) to provide primary healthcare services in Tanzania. Methods: We adopted a qualitative descriptive case study design. Qualitative research tools included document review and in-depth interviews with key informants, and data were analysed using a thematic approach. Results: Stakeholders reported mixed perceptions on the SA. The government considered the SA as an important mechanism for improving access to primary healthcare services where there were no public hospitals. The faith-based hospitals viewed the SA as a means of overcoming serious budget and human resource constraints as a result of the tightening funding environment. However, constant delays in disbursement of funds, mistrust among partners, and ineffective contract enforcement mechanisms resulted into negative perceptions of the SA. Conclusion: SAs between local governments and faith-based hospitals were perceived to be important by both parties. However, in order to implement SAs effectively, the districts should diversify the sources of financing the contracts. In addition, the government and the faith-based organizations should continually engage in dialogue so as to build more trust between the partners involved in the SA. Furthermore, the central government needs to play a greater role in building the capacity of district and regional level actors in monitoring the implementation of the SA.
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    Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation
    (International Journal For Equity in Health, 2018-10) Maluka, Stephen; Chitama, Dereck; Dungumaro, Esther W.; Masawe, Crecensia; Rao, Krishna; Shroff, Zubin
    Background: Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented. Methods: We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically. Results: The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. Conclusions: Tanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.
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    Decentralisation and Health Services Delivery in Four Districts in Tanzania: How and Why Does the Use of Decision Space Vary Across Districts?
    (International Journal of Health Policy and ManagementManagement, 2018-10) Kigume, Ramadhani; Maluka, Stephen
    Background: Decentralisation in the health sector has been promoted in low- and middle-income countries (LMICs) for many years. Inherently, decentralisation grants decision-making space to local level authorities over different functions such as: finance, human resources, service organization, and governance. However, there is paucity of studies which have assessed the actual use of decision-making space by local government officials within the decentralised health system. The objective of this study was to analyse the exercise of decision space across four districts in Tanzania and explore why variations exist amongst them. Methods: The study was guided by the decision space framework and relied on interviews and documentary reviews. Interviews were conducted with the national, regional and district level officials; and data were analysed using thematic approach. Results: Decentralisation has provided moderate decision space on the Community Health Fund (CHF), accounting for supplies of medicine, motivation of health workers, additional management techniques and rewarding the formally established health committees as a more effective means of community participation and management. While some districts innovated within a moderate range of choice, others were unaware of the range of choices they could utilise. Leadership skills of key district health managers and local government officials as well as horizontal relationships at the district and local levels were the key factors that accounted for the variations in the use of the decision space across districts. Conclusion: This study concludes that more horizontal sharing of innovations among districts may contribute to more effective service delivery in the districts that did not have active leadership. Additionally, the innovations applied by the best performing districts should be incorporated in the national guidelines. Furthermore, targeted capacity building activities for the district health managers may improve decision-making abilities and in turn improve health system performance.
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    Decentralization and Health Care Prioritization Process in Tanzania: From National Rhetoric to Local Reality
    (2011-03) Maluka, Stephen; Hurtig, Anna-Karin; Sebastian, Miguel San; Shayo, Elizabeth; Byskov, Jens; Kamuzora, Peter
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    Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania
    (2016-09) Mpambije, Chakupewa Joseph; Maluka, Stephen
    Background: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrollment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. Methods: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyze the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. Results: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. Conclusion: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.
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    The Failure of Community-Based Health Insurance Schemes in Tanzania: Opening the Black Box of the Implementation Process
    (BMC Health Services Research, 2021) Kigume, Ramadhani; Maluka, Stephen
    Background: Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania. Methods: A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data. Results: While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community. Conclusions: Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.
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    Geostatistical linkage of national demographic and health survey data: a case study of Tanzania
    (Population Health Metrics, 2021) Yoo, E; Palermo, T; Maluka, Stephen
    Background: When Service Provision Assessment (SPA) surveys on primary health service delivery are combined with the nationally representative household survey—Demographic and Health Survey (DHS), they can provide key information on the access, utilization, and equity of health service availability in low- and middle-income countries. However, existing linkage methods have been established only at aggregate levels due to known limitations of the survey datasets. Methods: For the linkage of two data sets at a disaggregated level, we developed a geostatistical approach where SPA limitations are explicitly accounted for by identifying the sites where health facilities might be present but not included in SPA surveys. Using the knowledge gained from SPA surveys related to the contextual information around facilities and their spatial structure, we made an inference on the service environment of unsampled health facilities. The geostatistical linkage results on the availability of health service were validated using two criteria—prediction accuracy and classification error. We also assessed the effect of displacement of DHS clusters on the linkage results using simulation. Results: The performance evaluation of the geostatistical linkage method, demonstrated using information on the general service readiness of sampled health facilities in Tanzania, showed that the proposed methods exceeded the performance of the existing methods in terms of both prediction accuracy and classification error. We also found that the geostatistical linkage methods are more robust than existing methods with respect to the displacement of DHS clusters. Conclusions: The proposed geospatial approach minimizes the methodological issues and has potential to be used in various public health research applications where facility and population-based data need to be combined at fine spatial scale.
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    Health Sector Decentralisation in Tanzania: Analysis of Decision Space in Human Resources for Health Management
    (Willey & Sons, 2019-04) Kigume, Ramadhani; Maluka, Stephen
    While decentralisation of health systems has dominated the political arena in the low and middle income countries since the 1970s, many studies on decentralisation have focused on understanding who is given more decision-making authority but less attention is paid to understanding what that authority involves. This paper assesses the range of decision-making authority transferred from the central government to sub-national levels in the area of human resources for health management in Tanzania. This analysis was guided by the decision space framework and relied on interviews, Focused Group Discussions and analysis of documents. Data were analysed using thematic approach. While districts had narrow decision space on recruitment and promotion of health service providers, they had wide decision space on distributing health providers within districts and providing incentives. Centrally managed recruitments resulted in frequent delays, thereby intensifying shortages of skilled health service providers. This analysis concludes that decentralisation of Human Resources for Health planning and deployment role to lower levels of the administrative hierarchy in Tanzania is limited. This suggests the need for the central government to increase decision space to districts in the area of recruitment. In order for the Ministry of Health to perform its functions better in the area of human resources for health management, there is a need to strengthen the capacity of the department dealing with recruitment of skilled health staff at the Ministry of Health.
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    . Health sector decentralisation in Tanzania: How do institutional capacities influence use of decision space?
    (International Journal of Health Planning and Management, 2018-06-29) Kigume, Ramadhani; Maluka, Stephen
    While decentralisation of health systems has dominated political arena in the low‐income and middle‐income countries since the 1970s, there is scarcity of studies on how organisational capacities influence the ability of the decentralised local‐level officials to use the available decision space. Using qualitative approach through in‐depth interviews and focus group discussions in 4 districts in Tanzania, this study explored how organisational capacities influence the use of decision space available in the 5 broad categories namely planning, finance, human resources, service organisation, and governance. The findings of the study indicated that while the district health managers had authority in many health system functional areas, limited capacity of the local government in financial resources highly affected their capacity to make use of the available decision space. In addition, while the district health managers had skills, knowledge, and experiences in preparing district health plans, health facilities and community representatives had limited capacity. Most of the health facilities had critical shortage of skilled health providers. Similarly, health committees had limited capacity in knowledge and skills. This study concludes that decentralisation will only improve delivery of health services when an appropriate degree of discretion is combined with adequate institutional capacities to enable exercise of those authorities. The district councils and the Ministry of Health should strengthen the capacities of health service providers and members of health committees and boards.
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    Implementation of Pro-Poor Exemption Policy in Tanzania: Policy Versus Reality
    (Wiley, 2013-09) Idd, Aisha; Yohana, Odongo; Maluka, Stephen
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    Implementing Accountability for Reasonableness Framework at District Level in Tanzania: A Realist Evaluation
    (2011-02) Maluka, Stephen; Kamuzora, Peter; Sansebastián, Miguel; Byskov, Jens; Ndawi, Benedict; Olsen, Øystein E.; Hurtig, Anna-Karin
    Despite the growing importance of the Accountability for Reasonableness (A4R) framework in priority setting worldwide, there is still an inadequate understanding of the processes and mechanisms underlying its influence on legitimacy and fairness, as conceived and reflected in service management processes and outcomes. As a result, the ability to draw scientifically sound lessons for the application of the framework to services and interventions is limited. This paper evaluates the experiences of implementing the A4R approach in Mbarali District, Tanzania, in order to find out how the innovation was shaped, enabled, and constrained by the interaction between contexts, mechanisms and outcomes. This study draws on the principles of realist evaluation -- a largely qualitative approach, chiefly concerned with testing and refining programme theories by exploring the complex interactions of contexts, mechanisms, and outcomes. Mixed methods were used in data collection, including individual interviews, non-participant observation, and document reviews. A thematic framework approach was adopted for the data analysis. The study found that while the A4R approach to priority setting was helpful in strengthening transparency, accountability, stakeholder engagement, and fairness, the efforts at integrating it into the current district health system were challenging. Participatory structures under the decentralisation framework, central government's call for partnership in district-level planning and priority setting, perceived needs of stakeholders, as well as active engagement between researchers and decision makers all facilitated the adoption and implementation of the innovation. In contrast, however, limited local autonomy, low level of public awareness, unreliable and untimely funding, inadequate accountability mechanisms, and limited local resources were the major contextual factors that hampered the full implementation. This study documents an important first step in the effort to introduce the ethical framework A4R into district planning processes. This study supports the idea that a greater involvement and accountability among local actors through the A4R process may increase the legitimacy and fairness of priority-setting decisions. Support from researchers in providing a broader and more detailed analysis of health system elements, and the socio-cultural context, could lead to better prediction of the effects of the innovation and pinpoint stakeholders' concerns, thereby illuminating areas that require special attention to promote sustainability.
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    Improving District Level Health Planning and Priority Setting in Tanzania Through Implementing Accountability for Reasonableness Framework: Perceptions of Stakeholders
    (2010-12) Maluka, Stephen; Kamuzora, Peter; Sebastian, Miguel San; Byskov, Jens; Ndawi, Benedict; Hurtig, Anna-Karin
    In 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, Tanzania. The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees. Individual interviews were carried out with different categories of actors and stakeholders in the district. The interview guide consisted of a series of questions, asking respondents to describe their perceptions regarding each condition of the Accountability for Reasonableness framework in terms of priority setting. Interviews were analysed using thematic framework analysis. Documentary data were used to support, verify and highlight the key issues that emerged. Almost all stakeholders viewed Accountability for Reasonableness as an important and feasible approach for improving priority-setting and health service delivery in their context. However, a few aspects of Accountability for Reasonableness were seen as too difficult to implement given the socio-political conditions and traditions in Tanzania. Respondents mentioned: budget ceilings and guidelines, low level of public awareness, unreliable and untimely funding, as well as the limited capacity of the district to generate local resources as the major contextual factors that hampered the full implementation of the framework in their context. This study was one of the first assessments of the applicability of Accountability for Reasonableness in health care priority-setting in Tanzania. The analysis, overall, suggests that the Accountability for Reasonableness framework could be an important tool for improving priority-setting processes in the contexts of resource-poor settings. However, the full implementation of Accountability for Reasonableness would require a proper capacity-building plan, involving all relevant stakeholders, particularly members of the community since public accountability is the ultimate aim, and it is the community that will live with the consequences of priority-setting decisions.