th Joint Annual Health

Transcription

1 9 th th Joint Annual Health Sector Review 8 th -10 th October 2008 Report Health Sector Reform Secretariat, DPP, Ministry of Health and Social Welfare.

2 Executive Summary The 9 th Annual Joint Health Sector Review took place at the Kunduchi Beach Hotel from 8 th to 10 th October The review drew upon the Technical Review Meeting where a number of technical areas were discussed in more depth. Several resource documents fed into the Review process, including the Technical Review Meeting Report, the Milestones Report, the draft Public Expenditure Review, the MTEF, and the final draft Health Sector Strategic Plan 2009 to The Honourable Minister of Health and Social Welfare formally opened the meeting and welcomed participant. The main focus of the review meeting would be the Health Sector Strategic Plan III which was developed in a highly participatory manner and with due consideration to existing policies, sector targets, and cross-cutting concerns like equity, quality of services and decentralisation. As the Health Sector Reform is moving into its final stage it was encouraging to observe that the partnership arrangements had been internationally recognized, most lately at the High Level Forum in Accra, Ghana in September The honourable Minter pointed at particular areas that still require attention including community involvement, hospital reform strategies, public-private-partnership, information systems, deficient funding of the sector, and the human resource deficit. In the ensuing session the FY 2007/8 health sector performance including milestones were presented and discussed. The early distribution of the Health Sector Performance Profile Report was appreciated and the discussion focused on some stagnating indicators, maternal health issues, and the human resource crisis. There is a need for the sector to inform about its successes and to advocate its requirement for financial and human resources. Presentations of the health sector financing included briefs on national health accounts, the National Health Insurance Fund and community health funds. The increased health sector funding was appreciated but it was also highlighted that substantial additional health sector funding is required to achieve the National health targets. The second day was entirely set aside to focus on the Health Sector Strategic Plan III The meeting was thoroughly introduced to the strategic framework, the eleven specific strategies and the cross cutting issue, which have been developed in a participatory process involving all major stakeholders since the last JAHSR in October The process leading to this final stage of the HSSP III was highly appreciated by many commentators. The discussion was very comprehensive and included all aspects of the strategic plan as well as the health sector. A large number of comments regarded requests to include and expand details on particular health sector concerns. It was agreed to update the organizational 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION II

3 diagram in the document. However, as the HSSP III was already exceeding the Government page limitations the Ministry could not promise to include all the details suggested by participants. The list of indicators for the strategic plan was not completed and the M&E Working Group was tasked with responsibility to complete this assignment. Likewise, the financing chapter needed to be revised and changed according to discussions at the meeting. A group of economists from the Ministry, Development Partners, Civil Society Organisations and the contracted consultant was charged with responsibility to complete this chapter. Finally, it was resolved that the MoHSW senior management would take note of all comments and information provided at the JAHSR meeting and direct the editing group to the final revision of the HSSP III document. On the third day PMO-RALG made a presentation of the new health window for infrastructure development designated the Health Sector Development Grant. The discussion was particularly critical about the restrictions for allocating the grant, which prohibit its use at the regional level and confine allocations to health facilities with minimum staffing levels, hence further disadvantaging areas that are already deprived. A work group would be established to continue the development of the funding mechanism and report to the Technical Working Group. The milestones for FY 2008/9 were already developed by a group of stakeholders. With a few remarks the final list of milestones was adopted. The General Budget Support Performance Assessment Framework was briefly discussed and the Ministry advocated that the measure be more elaborate and specific. The Permanent Secretary of MoHSW appreciated the active contributions and successful deliberations and subsequently he formally closed the meeting JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION III

4 Table of Contents Executive Summary...ii Table of Contents...iv Acronyms...v Opening Session...1 Presentation of Health Sector Performance FY 2007/8...4 Status of 2007/8 Milestones...5 Financing...9 DAY 2: Thursday 9 th October Presentation of Final draft HSSP III DAY 3: Friday 10 th October Presentation of new Health Window for Infrastructure...19 Review and agreement on Milestones 2008/ Agreement on sector progress for GBS/PAF process...21 Closing Session...21 Annexes Annex 1: Terms of Reference for Joint Annual Health Sector Review. Annex 2: Development Partner s Statement Annex 3: Opening Speech by Honourable Minister for Health and Social Welfare. Annex 4: Summary table of status of Health Sector Indicators FY 2007/8. Annex 5: Agreed Milestones FY 2008/9. Annex 6: Closing Speech by Permanent Secretary for Health and Social Welfare JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION IV

5 Acronyms ANC ARV CCHP CHF CMO CSO DED DMO DP DPG EmOC EPI FBO FY HIV HMIS HR HSSP ITN JAS LGA LGRP MCH MDG Mkukuta MMAM strategy. MMR MOF MOHSW MTEF NHIF OC PAF Ante-Natal Care Anti-Retroviral Comprehensive Council Health Plan Community Health Fund Chief Medical Officer Civil Society Organisation District Executive Director District Medical Officer Development Partner Development Partners Group Emergency Obstetric Care Expanded Programme on Immunisation Faith-Based Organisation Financial Year Human Immune-Deficiency Virus Health Management Information System Human Resources Health Sector Strategic Plan Insecticide-Treated Net Joint Assistance Strategy Local Government Authority Local Government Reform Programme Mother and Child Health Millennium Development Goal National Strategy for Growth and Reduction of Poverty Mpango wa Maendeleo wa Afya ya Msingi - primary health Maternal Mortality Ratio Ministry of Finance Ministry of Health and Social Welfare Medium Term Expenditure Framework National Health Insurance Fund Other Charges Performance Assessment Framework 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION V

6 PEPFAR PER PMO-RALG Government PPP PS RCH SWAp TBA TDHS TEHIP TMAP TOR TRCHS Presidential Emergency Plan for AIDS Relief Public Expenditure Review Prime Minister s Office Regional Administration and Local Public Private Partnership Permanent Secretary Reproductive and Child Health Sector-Wide Approach Traditional Birth Attendant Tanzania Demographic and Health Survey Tanzania Essential Health Interventions Project Tanzania Multi-sectoral AIDS Project Terms of Reference Tanzania Reproductive and Child Health Survey 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION VI

7 Opening Session The Permanent Secretary MOHSW formally welcomed the guest of honour, the Honourable Minister of Health, the Honourable Deputy Minister of Health, the Dutch, Swiss and Irish Ambassadors, Representatives from various UN organizations and other participants. The Director of Policy & Planning Department introduced the objectives of the 9 th Joint Annual Health Sector Review Meeting and reminded that the annual review is a regular event with the overall objective to review developments in the health sector, to consider the different sector performance and status reports, assess resources available for the sector, and agree on future priorities including the content of the next Health Sector Strategic Plan III and for the coming financial year 2009/10 (as detailed in the Terms of Reference for the Joint Review Annex: 1). The broad participation of stakeholders in the JAHSR reflects the commitment that all stakeholders have towards development of the health sector. The Chief Medical Officer recognized the huge task of developing the Health Sector Strategic Plan III ( ) and the thorough methodology and broad involvement of stakeholders that had guided the development of the HSSP III right from the JAHSR held in September There is need to emphasized expand the decentralization of local governments to enable health facilities manage and maintain their health expenditures accounts. The reduction of child mortality proves the improvements that have taken place in health service delivery. The speech also noted slow progress in hospital reforms, inequities in health across the regions, weakness of the health system, and human resource crisis. He concluded by, emphasizing the need to work together and in the same direction. Development Partners representative recognized and appreciated the evolution of the health sector dialogue as it has progressed with the JAHSR. Tanzania would attain MDG4 if this trend of improved child survival were to be sustained. Some major areas of concern also exist, including a lack of progress in maternal and neonatal health, slow progress in Hospital Reforms and substantial urban-rural, regional and socio-economic disparities among most health indicators. Human resources crisis will not go away if we continue business as usual. Lack of a comprehensive health financing strategy is impeding a sustained progress. The M&E systems are not producing information required for policy and planning, and M&E indicators are rarely used for decentralised decision making. Global Health Initiatives or Partnerships remain outside the existing health planning and management systems. The HSSP III needs to be a clear, focused plan. It should also be made sure how we hold each other accountable for achieving the HSSP III. The crucial factor for the success of the strategy will be how the government and stakeholders will monitor the implementation by utilizing the M&E framework of HSSP III; setting and monitoring annual and periodic targets and making 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

8 better use of the existing regular sector dialogue structure, such as the technical committee of the SWAp and specific technical working groups and committees. These sector dialogue structures will ease work of the understaffed Tanzanian government and other stakeholders and partners. 38 million Tanzanian are the owner of HSSP III. Suggestions for ensuring their larger engagement are greatly welcomed, particularly those from our colleagues at district level, the civil society, private sector representatives and politicians. Community, patient or client organisations plus professional association, will become increasingly important partners in formation and implementation of policy and planning. Increased joint implementation is the key to ensure that Tanzanian people will benefit from our efforts in the coming years (The detailed statement sees Annex: 2). The Chairperson of the Association of Private Hospitals appreciated the MoHSW for formulation of health reforms, steering them and that they are now bearing fruits. He stressed that the National Public Private Partnership (PPP) Steering Committee, launched in March 2008, is a notable milestone towards strengthening health service provision. The key mechanism for strengthening partnership between the government and private in implementing the reforms is the service agreement. To spearhead the implantation of PPP strategies, a full-time PPP secretariat is crucially needed. The private health sector will continue to be committed to the delivery of national health programs, e.g. reproductive and child health services, TB and Leprosy, HIV and AIDS care and treatment and Non Communicable Diseases programs. Challenges facing the private health sector include insufficient capital for development, procurement, and training, and lack of human resources. A serious problem is the price of drugs. Anti-malarial drugs enforced by the government are not made available to the private health sector through Medical Stores Department (MSD), and the private health sector must obtain those drugs from retailers at prices twenty times higher than the MSD rates. He reminded the government to consider making private hospitals to access ACT known as ALU for treatment of malaria which available only in government health facilities. The Civil Society Organizations statement was prepared by the Health Equity Group and presented by the representative from Youth Action Volunteers. This is the fourth participation of CSOs in JAHSR, and their participation is increasingly respected and institutionalized. The Civil Society Organizations statement called for urgent and collective action on persistent challenges to MoHSW, Ministry of Finance and PMO-RALG to ensure that: (1) Funds are disbursed on time and as budgeted to districts; (2) Reforms are working at the district level; (3) Women are receiving free services during pregnancy and child-birth; (4) Drugs, equipment and supplies are in place in all existing health facilities; (5) There is efficiency in budget allocation, being away from traditional and repetitive travels, workshops and 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

9 allowances; (6) Funds approved by Parliament are made available and utilized to achieve the intended purposes; (7) There are genuine efforts to implement annual plans and effectively utilize the budgets; (8) A citizen friendly budget book for the health sector is available; (9) Public money is efficiently spent and accounted for, and action is taken against abuse and misuse; (10) Public Expenditure Review recommendations are implemented; (11) the human resources for health crisis is urgently and systemically addressed; (12) Corruption is actively combated; (13) Sectoral linkage is clear in strategies and annual plans; (14) Health sector focuses on development of local capacities and autonomy of citizens in decision making and (15) All annual health sector milestones are realistically implemented and reported. The Permanent Secretary explained the processes related to the Sector Wide Approach and in particular the policy dialogue taking place at the Joint Annual Health Sector Review. He introduced the forum to the meeting agenda and explained the vision of the health sector Vision 20/25. A lot has been achieved already including the unique partnership between the many stakeholders in the health sector which allows a candid dialogue that lead the way for progress in the sector. The JAHSR is an opportunity for stakeholders to network and discuss experiences that will lay the ground for improvements in the sector. The Honourable Minister of Health warmly welcomed participants of the 9th Joint Annual Health Sector Review. In this JAHSR meeting, the main focus will be on HSSPIII , which will be discussed for endorsement by the forum. HSSPIII was developed taking into account the following factors that: (1) that the HSSPIII reflects the new National Health Policy, the MMAM, findings and recommendations of the External Evaluation, and various strategic plans of specific programmes; (2) implementation of various programmes and interventions are further consolidated and geared towards MKUKUTA targets and MDGs; (3) equity and other cross-cutting issues are addressed to ensure availability of quality services; and (4) that further decentralisation is achieved and sustained. The Health Sector Reform is now moving on to the last but one stage known as the consolidation phase, before the maintenance phase. At the High Level Forum in Accra, Ghana in September, Tanzania was praised for its tireless effort in alignment and coordination, particularly in the health sector. Partnership modalities and financing arrangements in the SWAp have proven workable and sustainable. With just 10 dollars per capita at our disposal for providing health services, Tanzania has nearly accomplished MDG4 and the move towards the realization of MDG6 is on track. However there is still room for improvement, such as enhanced solidarity with the communities and health services users, and strengthening of Public Private Partnership modalities and Hospital Reform strategies. Financing of escalating costs of providing health services is another daunting undertaking. Health human resources deficits require the most 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

10 urgent and maximal level of effort, including enhancing roles of the private sector and zonal resources centres. The regional level needs further strengthening to perform the roles expected from them. Every regional hospital should be a consultant hospital for its region. Zonal Specialized Referral Hospitals must reinforce its role as provider of specialist outreach services. Once HSSP III is endorsed, all regions and councils will be requested to develop their own Regional and Council Strategic Health Plans. Effective advocacy will be a key to ensure implementation of HSSP III at different levels of the health system. A viable Monitoring and Evaluation system, including a user friendly Health Management Information System, is essential to monitor progress towards the set targets. The close partnership with Development Partners, the Civil Society and other stakeholders is prerequisite to achieving an overall goal we have set for ourselves. Finally, the Minister expressed appreciation to the commitment of all partners and stakeholders, and formally opened the 9th JAHSR meeting (The detailed speech sees Annex: 3). Presentation of Health Sector Performance FY 2007/8 The Head of DPP Information & Research Section initially thanked colleagues from the Ifakara Research Institute for assistance to write the draft Health Sector Performance Profile Report 2007/8. The Health Sector Performance Profile Report 2008 Update including the health sector performance indicators were distributed to the participants prior to the JAHSR. The report presented the assessment of health system performance in Mainland Tanzania for financial year Drawing from available survey and routine information, the overall picture was fairly encouraging, particularly with regard to childhood mortality trends, malaria control, HIV prevalence and TB control. In contrast, there was slippage in the coverage of DPT-Hb3 in children less than 1 year of age. Reporting on the 33 health indicators is hampered by the lack of robust HMIS data, on which many of the indicators depend. This highlights the importance of reinvigorating the HMIS system. From next financial year, the indicator set is due to be revised. It will be replaced by a new set of indicators, as per the Monitoring and Evaluation Framework of the new HSSP III. Resources for the health sector as a whole have increased, particularly at the Regional and Council levels. However, the sector did not increase quite as rapidly as the total government resource envelope. The human resource situation is still a cause for grave concern. While there has been a major increase in payroll expenditure, this is almost entirely due to wage inflation rather than an increase in the number of health workers (A summary table of Performance Indicators for refers Annex: 4) JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

11 Status of 2007/8 Milestones The milestone status was presented as follows: MILESTONE STATUS PROGRESS REMARKS 1. Develop a Health Partially A broad strategy for health financing is part of the This will be part of the new Care Financing Strategy achieved Health Sector Strategy Plan III. milestones for 2008/09. that will input for HSSP III by June A Medium Term Fully The generic document outlining the Medium A copy is already availed to Strategy for the health achieved Term Strategy for health basket fund has been respective members. basket funds is completed and a memorandum of understanding developed by the end to that effect has been signed between of December 2007 Government officials and DPs representatives in August Increase enrolment Partially Enrolment for pre-service for all levels of The detailed information in pre-service training achieved certificates, diploma and degree in the public and on enrolment by cadre has from the current 1,013 private sector has increased from 1,013 in 2006 been availed. in 2006 to 6,458 in to 3,831 in The target has been achieved The Govt will put more 2008 approximately by 60%. Govt has increased grants effort to encourage and from Tsh. 30,000 to Tsh. 40,000 per student. support private sector A detailed assessment of the situation in all health training colleges to health training institutions is being done. increase pre-service enrolment. 4. Develop/ establish Partially The scheme of service for all health cadres has The process of determining innovative achieved been finalised and is awaiting approval by the incentives and retention mechanisms to foster Master Workers Council in Nov particularly in the hard to and monitor HRH New Salary structure for health cadres has been reach areas is ongoing by retention, productivity introduced i.e TGHS. Starting salaries has been PoPSM. and motivation by raised. August Health workers have access to Bank Loans. Improvement of working environment i.e supply of drugs, working tools, renovations of buildings etc is ongoing. Promotions of most of the health staff and revised allowances such as uniform allowances, travelling allowance and per diem Under the Emergency Hiring Programme and Benjamin Mkapa HIV/AIDS Foundation, Fellows have been hired and posted to hard to reach areas. At the end of their contract some have been absorbed in public sector The process of establishing. Comprehensive Information system for HR is ongoing. A stakeholders meeting including POPSM to identify gaps and needs was conducted in July National Medicines Partially The National Medicine Policy has been reviewed The Policy is being finalised Policy and master achieved and formatted in line with the Cabinet Secretariat and will be submitted to the 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

12 MILESTONE STATUS PROGRESS REMARKS plan disseminated, Manual, in August Cabinet Secretariat for and the new drug The draft Master Plan for the Pharmaceutical process of Cabinet allocation formula Sector will be developed in October approval. used to allocate drugs A consultancy report on development of an and medical supplies Equitable Resource Allocation Formula for to districts and Medicines and Medical Supplies was submitted to hospitals starting MOHSW in November The Pharmaceutical FY08/09 Sub Committee approved the drug resource allocation formula based on: - Population (70%), - Disease Burden under five 15%), - Poverty index (15%). Appropriate forms/tables for the formula have been developed. 6. Mapping of public Partially The mapping is at a stage where the exercise of The Ministry and and private services achieved health facility listing and verification is ready. The PMORALG will use GIS providers is next stage is to collect geo-code information from National Electoral completed by March (positioning of HF) as well as availability of health Commission and other services. sources to validate its data 7. Assessment of Partially Assessment of CCHPs was done. However, the The CCHP guidelines and CCHPs for FY08/09 achieved activities from FBO and private for profit sector assessment tools will be concluded that there are not well captured. reviewed so that the is greater inclusion of The FBOs activities are financed according to the inclusion of CSOs, FBOs FBOs, CSOs and guidelines. Nevertheless, there is no provision in and Private Sector is explicit private sector the guidelines to use Government block grants activities. and health basket funds to fund private for profit activities. The MOHSW advised PMORALG to instruct the LGAs to include activities in the CCHPs to address FBOs, CSOs, NGOS, and Payment for Performance (P4P). 8. TORs (roles & Partially TORs (roles and functions) for RHMTs, Regional The signed document will functions) for RHMTs achieved Referral Hospital Management Teams, and be shared with all RSs and have been produced Regional Referral Hospital Boards have been RHMTs. and there is an developed, approved and signed by MOHSW and Budget line for RHMTs is explicit budget line for PMORALG. However, in the 2008/09 budget, not yet established by the RHMTs in the each region has allocated 100 million TSh. to MOFEA. vote of the Regional facilitate RHMTs to carry out their supervisory role Administrative to LGAs. Secretary FY08/09 MTEF 9. All referral hospitals Partially All eight referral hospitals have Annual Plans In the revised National and regional hospital achieved prepared from their Strategic Plans. Health Policy 2007, the have annual plans Eight Regional Hospitals have annual plans and current referral hospitals will (per the planning & the remaining 13 will be covered through the provide super specialty reporting guidelines) ongoing hospital reforms. health services while as basis for their regional hospitals will act as budgets for FY08/09 a referral hospitals 10. National PPP Fully A plan was prepared and presented in the last Bi- Initial efforts have been Steering committee achieved Annual SWAp meeting held in April done. However, more 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

13 MILESTONE STATUS PROGRESS REMARKS has produced a plan MOHSW prepared a budget for implementing advocacy to LGAs is and budget for the Service Agreement (by all Local Governments) needed. implementation of the and requested PMO-RALG to instruct all Local Service Agreements Governments to start using the document to make for approval by SWAp agreements as a strategy to effect MMAM. Technical Committee Advocacy was conducted to Zonal centres and by December 2007 Regions Some councils have signed the agreement and the process is ongoing. 11. Operational Plan Not MTEF and POA for MOHSW for have Operational Plan for based on new achieved been operational up to June 30th 2008 not basing 2009/10 will be based on Monitoring and on a new M&E strategy as it was not yet ready. HSSP III which includes Evaluation Strategy However, the operational plan for 2008/09 is M&E strategy. be developed by based on HSSP III which includes an M&E December 2007 strategy. 12. Health Sector Partially Draft for Health Sector Performance Annual There were some Performance Annual achieved Report for 2008 has been completed and will be difficulties in gathering Report disseminated disseminated after getting more inputs from this health data indicators in by August JAHSR meeting. time. 13. (a) Capacity Fully The Strategic and Business plan for Zonal Health Development Plan to achieved Resource Centres have been developed support ZTCs, National roadmap for the acceleration and regional & district reduction of maternal, newborn and child health health management is in place indicating effective teams to be interventions to be implemented at all levels. developed. (b) MNCH Roadmap interventions to be developed and completed 14. Nutrition s focal Not The Ministry has reviewed its scheme of service In order to accomplish fully point designated in all achieved to include Nutrition cadre. After approval of the this task, the milestone will Local Government same by POPSM, and the post established in the be extended to June Authorities by March LGAs, the MOHSW will work closely with 2008 PMORALG to post staff to LGAs. In interim due to short of this cadre, some existing staff will be reassigned to LGAs to perform nutrition related tasks. 15. Work place HIV/ Partially Workplace HIV and AIDS Program are being The Ministry is now in AIDS programmes achieved implemented according to the Strategic Plan for preparation of: are instituted HIV and AIDS for Health Workers ( ) Strengthening M&E throughout the Health Developed and launched an HIV and AIDS strategy on this programme sector by August Strategic Plan for Health Workers Holding a MoHSW 2008 Developed HIV and AIDS Workplace Intervention family/fun day Training of (WPI) Guidelines and Training Manuals regional and district TOTs Trained 25 HIV and AIDS departmental Procurement of 500 Coordinators condoms dispensers for all Trained 20 Peer Educators MoHSW departments and Trained top management for MoHSW including institutions Directors, Assistant Directors and RMOs on HIV 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

14 MILESTONE STATUS PROGRESS REMARKS and AIDS WPI Supervised the Manyara, Kagera, Mbeya, Mara, Mwanza, Tanga, Kigoma, Kilimanjaro, Arusha and Iringa Regions for the implementation of HIV and AIDS WPI Conducted Knowledge, Attitude and Practice Survey DISCUSSION The distribution of the Health Sector Performance Profile Report 2008 Update prior to the 9 th JAHSR was greatly appreciated by the participants. Some indicators show favourable progress such as childhood mortality, tuberculosis control, HIV prevalence, ITN coverage, and the increase in public expenditure on health. Other indicators and in particular some RCH related indicators were less encouraging and concern was raised on the progress of the PAF indicators TB treatment completion rate, DPT coverage and mothers attended by skilled birth attendants. A number of performance indicators require additional clarification on denominators as well as numerators. However, the meeting suggested that the mass media is used to advocate the successes that are reported by the profile. Many participants expressed concern about the high Maternal Mortality Ratio (MMR).The latest available data was taken from Tanzania Demographic and Health Survey (TDHS) 2004/5 and no new national estimate of maternal mortality would be available until next TDHS that is expected around The Hon Minister was concerned on the statistics for maternal mortality; he however mentioned that there are several interventions to address this issue including the development of meaningful and feasible RCH related indicators and milestones that would provide clarity that would help address this persistent issue. The importance of sensitizing PMORALG, community development officers and health workers and also to focus on men was underscored. Another focused area of discussion was human resources for health crisis particularly in the rural areas. Several participants stated the importance of increasing incentives for health personnel to go to rural areas and retain them there by offering good staff housing, providing motorbikes etc. Training of more doctors is a problem to be tackled urgently. There are also problems in recruitment of doctors; despite the fact that doctors are produced in relatively large numbers of about 400 yearly they are not all absorbed in the government system. The problem was with hospitals to undertake internship and the MOHSW had resolved this problem by increasing the number of hospitals in which medical internship can be undertaken. The process of government permits to recruit health staff was seen to be unclear; however, the 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

15 MOHSW is planning to review and reinforce the process. It was suggested that the RHMTs should be encouraged to support councils to manage their human resources in health. The insufficient involvement of CSOs, FBOs and the private sector in the process of formulating district health plans were regretted and it was suggested that particular efforts should be made to include all stakeholders in the CCHP planning and monitoring processes. With regards the poor availability of drugs and medicinal supplies a main reason appeared to be delay of funds from government. The view that the functioning of MSD should be the main problem appeared to be a misconception and MSD was advised to advocate its performance. Financing PUBLIC EXPENDITURE REVIEW 2007 The public health sector budget growth has increased annually 38% in FY2005/6, 22% in FY2006/7 and 24% in FY2007/8. However, the budget for the sector has fallen as a share of the total government budget from 11.4% in FY2007/8 to 10.8% in FY2008/9. The actual annual public health sector financing increased by 33% in FY 2005/6 and 23% in FY 2006/7. In 2007/8 the budget increase was due to PE and capital costs. Over the past four years an increasing proportion of public health sector allocation goes to the central level from 28% in FY 2004/5 to 36% in 2007/8. Budget performance has increased slightly to 91% in recent years; however the development budget has only been executed to the tune of 84% in the recent FY2007/8. The per capita spending has increased from 7.32 US$ in FY 2004/5 to US$ in FY 2007/8. Some challenges are lengthy procurement processes for goods, services and works, and the delay and inadequate releases of funds. As PER plays a key role in allocation, utilization and projection of resource envelope in the health sector, there is a need for all stakeholders to participate in the process annually. The necessary data should be collated prior to actual exercise. Also, the external funding database should be improved to ensure inclusion of other donor funds in the government books. BASKET FUND INCOME AND EXPENDITURE STATEMENT FY 2007/8 The total receipt of the Health Sector Basket Fund was Tsh billion in 2007/08 and Tsh billion in 2006/07. The total payment was Tsh billion in 2007/08 and Tsh billion in 2006/07. The total assets in the holding account were USD billion in 2007/08 and USD billion in 2006/07. A largest part of the cash flow took place in the 2nd and 3rd quarter while no disbursement was made in the 1st quarter JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

16 There are unspent funds totalling Tsh billion. The funds remain unspent due to late completion of procurement of works contractor where the contract signing upcountry was mostly done in June 2008 hence no certificate to pay. The remaining part was earmarked for procurement of motor vehicles, but due to a change in government policy, all Ministries, Departments and Agencies had to procure those goods through the Ministry of Infrastructure. But for the Basket Fund modality, MOHSW could not send funds to the Ministry of Infrastructure. Instead MOHSW requested the State House authority to permit MOHSW to procure motor vehicles by itself, but the permit came out late and motor vehicles were not procured. NATIONAL HEALTH ACCOUNTS The principles of calculating National Health Accounts were briefly explained. The last NHA were established in 2002/3. Household spending has decreased dramatically as out-of-pocket expenditure has decreased from 42% in FY 2002/3 to 23% in FY 2005/6. DP funding has almost doubled while health insurance contribution has increased slightly. In addition it is observed that people increasingly uses public health facilities. SUMMARY OF MTEF 2008/9 MOHSW AND PMO-RALG Presentation of MTEF from MoHSW The Head of Budget, Department of Policy and Planning, MOHSW outlined the structure of the MOHSW MTEF and its preparation process, and summarized the budget allocation and priority areas for 2008/09. The priority areas for resource allocation for MTEF 2008/09 include: reproductive and child health services including IMCI, prevention and treatment of Malaria, improving human resources capacity, strengthening provision of immunization services, scaling up proven non-arv interventions, rehabilitation and expansion of training institutions, procurement and supply of medicines, reagents and other medical supplies, environmental health, strengthening provision of services for referral and voluntary hospital, promoting and implementing programmes particularly to women, children, elderly care, widow- and child-headed households, and prevention and control of HIV/AIDS and TB. The 2008/09 MTEF was prepared in line with the MKUKUTA framework. The overall budget to the MOHSW, which consists of recurrent and development, has increased by 19% from Tsh billion for 2007/08 to Tsh billion for 2008/09. Personal Emoluments (recurrent spending on wages) spending increased moderately by 14% from Tsh billion for 2007/08 to Tsh billion for 2008/09. Other Charges (non-wage recurrent spending) allocation is Tsh billion for 2008/09, which is the same figure as 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

17 2007/08. Development Spending increased by 33% from Tsh billion for 2007/08 to Tsh billion for 2008/09, largely due to a large increase in the Basket Fund and other funds while the government fund has doubled and contributed to the increase. Challenges are how the sector will respond to a shortage of human resources in the health sector, high maternal and infant mortality rates, new HIV/AIDS transmission, scaling up of ARV provision and inadequate funds to implement MMAM. Presentation of MTEF from PMO-RALG PMO-RALG funding for the health sector reflects two major components. One is Council Comprehensive Health Plans (CCHPs) for addressing health problems in six health priority areas of the Essential Health Package. The other concerns the rehabilitation of primary health care facilities. In 2008/9, LGAs and RHMTs have been instructed to include Payment for Performance activities in their plans. For 2008/9, the PMO-RALG budget from the Health Basket Fund is Tsh billion. There is an overall decrease of 10.98% over the last year s Basket Fund allocation of which Tsh billion is directed to activities in CCHPs, Tsh. 1.1 billion to the District Health Infrastructure Rehabilitation Component (DHIRC), Tsh billion to Central, and Tsh. 2.1 billion to RS/RHMTs. The block grant to the health sector has increased by 6.83% from Tsh billion (actual) for 2007/08 to Tsh billion (budget) for 2008/09 of which Tsh billion goes to the LGAs and Tsh billion to DHIRC. The main challenges include delays in funds disbursements, delays in preparation and submission of quarterly progress reports by the LGAs, LGAs failure to report annually achievements of the planned objectives, unsatisfactory audit opinions for the CHBF, and poor conditions of health facilities and increasing number of population against available health facilities. RS/RHMT should support LGAs so that they would perform tasks more proactively. THE POTENTIAL OF NHIF FINANCIAL CONTRIBUTION TO THE HEALTH SECTOR The objectives for establishment of NHIF are 1) to have a reliable system for the public sector employees and their families to contribute towards their health care; 2) to promote public private partnership; 3) to expedite improvement of the health sector by complementing the Government health budget; and 4) to improve the availability, efficiency and quality of health services. To attain these objectives, the NHIF implements activities such as provision of medical equipment loan and facility improvement loan to health facilities, development of health services infrastructure, and donations for social welfare activities. NHIF is expected to 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

18 contribute the following: 1) Accreditation of ADDO s in rural areas to meet the challenge of out of stock of drugs, 2) sensitization of various health facilities to lodge their claims promptly, 3) orientation to the provider to utilize equipment loan or facility loan more effectively, 4) full utilization of the funds for improvement of respective health facilities, that are reimbursed to health facilities. COMMUNITY HEALTH FUNDS AND COST SHARING The CHF/TIKA Coordination Unit of DPP reported on the potential of cost-sharing options. The adoption of cost-sharing policy in 1993 paved a way for introduction of Community Health Fund (CHF) in 1996 and National Health Insurance Fund (NHIF) in Costsharing options have proven effective in achieving sustainable financing, but there remains a significant challenge of how to balance it with equity and access. Other challenges include improving CHF performance, developing regulatory framework as a way forward on development of public health insurance schemes, strengthening CHF/TIKA Coordinating Unit at national, zonal, regional and council level. THE POTENTIAL OF FAITH BASED ORGANIZATIONS (FBO) OWNED FACILITIES CONTRIBUTING TO THE FINANCING OF THE HEALTH SECTOR The FBOs started to provide health services in Tanzania since 1920s. The strategies of FBOs based on Vision 2025 and focus on an empowering culture; competence and competitiveness; and good governance. Good governance must be cultivated by promoting accountability and clear incentive mechanisms to everybody. The importance of public-private partnership (PPP) is mentioned in the National Health Policy as well as in the Health Sector Strategic Plan III. The FBOs have been contributing the health sector through construction and rehabilitation of infrastructure (facilities), application of incentive schemes, and promotion of HMIS with computerized system. Cost sharing is the most reliable mode of financing for the FBOs health services and contributes 30-60% of hospital income. Some challenges exist including lack of effective policy on implementation and inadequate commitment to operationalizing the PPP concept. Therefore it is required to develop effective mechanisms for FBOs to fully contribute in financing the health sector and to promote joint planning, implementation, monitoring and evaluation of national policies at all levels. Advocacy on PPP should be intensified. THE PRIVATE HEALTH SECTOR POTENTIALS TO FINANCING THE HEALTH SECTOR 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

19 Program Manager of the Association of Private Health Facilities in Tanzania outlined the potentials of the private health sector. Since the law forbidding private medical practice was repealed in 1991 after 15 years of enforcement, the private health sector has shown a progressive growth. More than 25% of health care services are now provided by the private health sector. Approximately 40% of paramedical schools are private and 4 medical schools are privately owned. The areas for potential interactions between the public and private health sectors include procurement of supplies and equipment, subsidised service provision, service contracts to deliver a set of services for public facilities, delivery of predefined services for the public sector in private health facilities, management contract with public facilities, temporary operation and management of public facilities by the private sector, capital investment by the private sector and transfer of ownership to the public sector, and sale of public facilities to the private sector. By utilizing the private health sector fully, the government spending on health will be effectively utilized. What is required now is a good regulatory mechanism and conductive investment environment for the private health sector. DISCUSSION (TOOK PLACE ON DAY 2 IN THE MORNING) To the issue of GoT relative declining contribution of funding the public health sector the meeting was initially informed about the budgeting process. It was found important to consider not only the percentage of government budget allocation to the health sector but also to look at the nominal figures, i.e. in a situation where the total government budget increases dramatically. Hence, relatively the health sector was not doing badly when, in spite that the GoT allocation seems to decrease as a fraction, this is a result of a very large increase in the total government budget. It was observed that budget execution remains a problem. Some funds are released late and some never released at the end of the year. That negatively affects the planning and execution of sector activities. This would be looked further into in future PERs. With respect to timely funding of activities, GoT must necessarily allocate funds according to availability in Treasury; OC, for instance, depends on taxation and this sets the ceiling for each sector. Health sector is the third priority, but is given more development funds compared to other sectors. It was suggested that a meeting with DPs in May every year should look into securing early funding of activities in the following FY. The study report on disbursement of Health Basket Funds would be used to address the observed obstacles to allow smooth flow of funds. The next SWAP meeting should discuss how the flow of funds takes place. A main issue for discussion was the disbursement of funds to MSD. The government is looking for a possibility of crediting MSD Accounts directly from Ministry of Finance rather than going through Ministry of Health and Social Welfare JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

20 It was recommended to regularize and institutionalize in government systems the National Health Accounts, the Demographic Health Survey and Household budget surveys. It was suggested to develop a simple PER format that could feed into the JASHR held in October in the FY immediately after the completed financial year under review. It was appreciated that NHA shows that public funds are spend on cost effective interventions, and that out-of-pocket is reducing and pooled funding (including Government funding) is increasing. The challenge of finding the right balance between preventive and curative health services was acknowledged and it was emphasised that increased funding of the sector is a high priority that should be resolved also by developing alternative health financing mechanisms in the coming years. In this respect procedures for contracting out is already sent to the councils and some of the councils are in full swing contracting FBO and other health service providers. DAY 2: Thursday 9 th October Presentation of Final draft HSSP III Initially the HSPS Coordinator explained the formulation process that was commenced immediately after the JAHSR It was emphasized that the formulation process has been very participatory involving hundreds of stakeholders. The HSSP III reflects the strategic intentions of the health sector for the period It does not go into detail of operational activities, which will be provided in specific strategic plans and work plans of institutions and programmes. The document is a guide for strategic planning at sub-national levels and for annual planning. The health sector is guided by national policies, such as Government Reforms. The National Strategy for Development and Poverty Reduction (MKUKUTA) provides the global direction for achievement of the Millennium Development Goals (MDGs). The Health Policy was updated in 2007, providing Government s vision on long-term developments in the health sector. The Health Sector Reforms programme continues with further strengthening of Local Government Authorities and hospitals to improve their performance. The Primary Health Care Strengthening Programme aims at improving accessibility and quality of the health services. The Human Resources for Health plan targets at solving the human resources crisis in the sector. The eleven proposed strategies concentrate on specific topics in the health service delivery related to diseases and management. The crosscutting issues elaborate on the approach towards quality, equity, gender and governance. The document explains which types of 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION

21 services are provided in the health sector, and also explains what are the role and responsibilities of each level in the health system. Strategy 1 refers the accessibility to District Health Services that will be improved, amongst other through implementation of the Primary Health Care Strengthening Programme (MMAM). All facilities will provide a complete package of essential health interventions in accordance with the guidelines for their level. Community involvement will be strengthened, to improve health. The referral system in the district (horizontal and vertical) will be strengthened to ensure appropriate treatment for patients. The Tanzania Quality Improvement Framework (TQIF) provides guidance for introduction of quality systems, including accreditation. Supervision by Regional Health Management Teams (RHMTs) and Regional Hospital staff will contribute to quality improvement. With regard to management of District Health Services, further decentralisation to health facilities will improve needs-based planning and implementation. Further integration of MOHSW and LGA management systems will streamline operations. Performance-based systems like Pay-for-Performance (P4P) will enhance motivation and productivity of health workers. Strategy 2 concerns the Referral Hospital Services which will be more accessible to patients who need advanced care through an adequate referral system, and measures to prevent bypass. The quality of care will improve by implementation of the TQIF, and hospitals will have a Quality Assurance unit to promote quality. The hospital reforms programme will improve financial management and human resources management. Hospitals will develop strategic plans and capital investment plans. Hospital boards will ensure community participation in management. Strategy 3 regarding the National level support by headquarters departments and agencies will be streamlined. More functions will be delegated to operational level. Further integration of programmes will lead to more coherence in the health services. Head quarters will introduce a rigorous system of annual action planning. Strengthening of RHMTs is important for technical supervision on behalf of the MOHSW. Zonal Resources Centres provide training and technical support to training institutions. Strategy 4 involves the increase of numbers and improvement of the quality of human resources for health and social welfare. These are most important for improved accessibility and quality of health and social welfare services. The HRH planning and information system will be strengthened. Recruitment and retention of staff will be institutionalised in close collaboration with LGAs. The introduction of performance-based systems will improve motivation and productivity of health staff. Continuing Professional Development is 2008 JAHSR MEETING 8 TH TO 10 TH OCTOBER, KUNDUCHI - EDITION