MINUTES TECHNICAL REVIEW MEETING

Transcription

1 MINUTES TECHNICAL REVIEW MEETING Preparatory meeting in advance of Joint Annual Health Sector Review 2008 BELINDA HOTEL 3 rd - 5 th September 2008 Prepared by Health Sector Reform Secretariat Directorate of Policy and Planning Ministry of Health and Social Welfare

2 EXECUTIVE SUMMARY This report like the previous technical review reports provides a brief record of the proceedings of the Technical Preparatory Meeting that took place at Belinda Hotel, 3 rd - 5 th September The report does not provide an exhaustive record of all discussions in the plenary or work groups. Rather, it highlights the issues that are to be carried forward to the Main Review. Apart of the general issues related to the management of health services, the review discussed in more in-depth the following areas; Performance assessment report, Public Expenditure review report, progress on milestones, the proposed Health Sector Strategic Plan and indicators to monitor its performance. The purpose of the meeting was to: 1. Review progress in implementation of the 2 nd HSSP a. Assess progress against 2007/8 milestones b. Report upon service delivery performance since the September 2007 JAHSR (using the health sector performance profile, MKUKUTA Monitoring Report, HMIS/routine data system, and reports from health programs) c. Budget execution (PER, Income and Expenditure Statement) 2. Review the draft Health Sector Strategic Plan III ( ) that has been developed jointly between stakeholders since the September 2007 JASHR. 3. Share important policy developments (The 2008/2009 budget of the MOHSW, Payment for Performance strategy, draft strategy for Non-communicable Diseases, RHMT strengthening). 4. Agree upon specific priorities for the fiscal year 2009/2010. The presentation of health sector performance during FY 2007/8 was hampered by the fact that not all data is collected so early after the end of the year. Financial indicators show an increasing trend in recent years. While malaria indicators demonstrate positive trends compared to 2004/5 data, some maternal, reproductive and child health indicators seems to be stagnating. The discussion revealed concern with the stagnating performance of some indicators and methodological issues were raised. It was questioned if the timing of the JAHSR was optimal for presenting complete, validated data. Not all of the 15 milestones set for FY 2007/8 were fully achieved. The group work on milestones undertook the valuable task to updating and commenting on the milestones (attached as Annex 1). It was agreed to try to define future milestones as specific, measurable, realistic and time bound. The Public Expenditure Report presentation highlighted the substantial increase in health sector budgets during the past 3 years. The budget item increase has moved from personal emoluments (2005/6) to development budget (2007/8). However, budget execution has decreased significantly with a low of 84% in FY 2007/8. Though the PER has room for improvement, the annual undertaking was considered important. The meeting suggested certain improvements of the PER including change of timing to March-June every year. The Comprehensive Council Health Plans have improved substantially this year. A number of specific recommendations for improvement of the planning tool and its implementation were suggested. It was underscored that delay of funding was detrimental to execution of CCHPs. The draft Health Sector Strategic Plan III ( ) was presented and discussed in groups as well as in plenary. The plan has been developed over the past year through a very inclusive and thorough process where a large number of stakeholders have participated. The meeting was not expected to reiterate the process of reconciling a balanced strategic plan; but some suggestion regarding focus and presentation of the plan were expressed in the discussions and agreed to be taken into consideration while finalizing the document. Three work groups provided in-depth analysis of financing, monitoring and evaluation, and the human resource issues related to HSSP III. The Payment for Performance reform plan was presented and the discussion focused at the complexity of the reform and the risks of creating inappropriate incentives. Also the draft strategy for non-communicable diseases and the status of the Regional Health Management Team strengthening were presented and discussed. It was decided to refer planning of FY 2008/9 Milestones to a small work group, and to request the M&E group to suggest HSSP III indicators ahead of the JAHSR main meeting 24 th -26 th September

3 TABLE OF CONTENTS EXECUTIVE SUMMARY...2 TABLE OF CONTENTS...3 ACRONYMS...4 OPENING PLENARY...5 PRESENTATION OF HEALTH SECTOR PERFORMANCE PROFILE REPORT...6 STATUS OF MILESTONES...6 PUBLIC EXPENDITURE REVIEW SUMMARY COMPREHENSIVE COUNCIL HEALTH PLANS...8 HEALTH SECTOR STRATEGIC PLAN III ( )...9 HSSP III FINANCING GROUP PRESENTATION...12 HSSP III MONITORING & EVALUATION GROUP PRESENTATION...13 HSSP III HUMAN RESOURCES GROUP PRESENTATION...13 PAYMENT FOR PERFORMANCE P4P...13 DRAFT NCD STRATEGY...14 STATUS OF RHMT STRENGTHENING...15 MILESTONES FOR 2008 / PERFORMANCE ASSESSMENT FRAMEWORK FOR HEALTH SECTOR...15 PRIORITIES FOR 2009 / CLOSING REMARKS...16 ANNEX 1 - STATUS OF MILESTONES

4 ACRONYMS ACT ADDO ART ARV CSO CHMT CHF CHSB CMO DHS DMO DPP EmOC FY GBS GFATM HMIS HRH HSRS ICPP IEC IMCI ITN JAHSR JAS M&E MKUKUTA MOHSW MOF MTEF MSD NGO NHIF PLHA PMO-RALG PMTCT PPP POPSM PS RCH RRHM RHMT STI SWAP TBA TEHIP TOR TQIF VCT ZHRC Anti-malarial Combination Therapy Accredited Drug Dispensing Outlet Anti-Retroviral Therapy Anti-Retroviral Civil Society Organisation Council Health Management Team Community Health Fund Council Health Service Board Chief Medical Officer Demographic and Health Survey District Medical Officer Directorate of Policy and Planning Emergency Obstetric Care Financial Year General Budget Support Global Fund for AIDS, TB and Malaria Health Management Information System Human Resources for Health Health Sector Reform Secretariat International Committee on Planned Parenthood Information Education Communication Integrated Management of Childhood Illness Insecticide-Treated Net Joint Annual Health Sector Review Joint Assistance Strategy Monitoring and Evaluation National Strategy for Growth and Poverty Reduction Ministry of Health and Social Welfare Ministry of Finance Medium Term Expenditure Framework Medical Stores Department Non-Government Organisation National Health Insurance Fund People Living with HIV Prime Minister s Office Regional Administration and Local Government Prevention of Mother-to-Child Transmission Public Private Partnership President Office Public Service Management Permanent Secretary Reproductive and Child Health Regional Referral Health Management. Regional Health Management Team Sexually Transmitted Infection Sector-Wide Approach Traditional Birth Attendant Tanzania Essential Health Interventions Project Terms of Reference Tanzania Quality Improvement Framework Voluntary Counselling and Testing Zonal Health Resource Centre

5 OPENING PLENARY Participants were welcomed by Acting Chief Medical Officer, who apologized that a team of senior managers from the MOHSW cannot effectively participate in this review since they were participating in international meetings. The opening address was presented on behalf of the CMO, by the Health Sector Programme Support Coordinator, from the office of the DPP. The opening remarks outlined the main focus of the Technical Review meeting this year to be: Draft milestones implementation report Draft HSSP III Annual Health Sector Performance Profile PER Summary CCHP report P4P Draft NCD strategy Strengthening RHMT It was underscored that a long process has taken place to prepare the HSSP III document and that it was not the intention of the meeting to repeat the entire process; rather it was the intention to keep the assessment to the strategic level. The review was expected to take stock of developments and challenges experienced during the past and present year, and challenges should be assessed and dealt with. The technical review should focus on the development of the whole sector and views should cover the sector in its entirety rather than in terms of discrete areas of personal expertise or vertical programmes. The workable interactions and relations in terms of synergies between components of the sector constitute the elements of a functioning Tanzanian health system, with each being equally important to complete the circle. The meeting should address the financing gap that continues to hamper development in the health and social welfare sector. At the end of the three days the expected outcome would be: Agreed inputs into the draft HSSP III document M and E evaluation content and arrangements Proposal on way forward on PER and health financing Preliminary priorities for 2009/2010 MTEF Agreement on proposed draft Milestones Agreement on a revised Agenda and presentations for the Main Review meeting This would be the final step in the preparation for the Joint Annual Health Sector Review meeting scheduled for 24 th to 26 th September. The opening remarks appreciated the efforts that were made by, the Technical Planning Groups, in reviewing the HSSP II strategies, prioritization of areas in the HSSP III and the initial write up. Without that effort, the development of the HSSP III would not have come to this stage. Finally the chair recognised the work of the HSRS and the team of three consultants, and declared the Technical Review meeting open TECHNICAL REVIEW MEETING page 5

6 PRESENTATION OF HEALTH SECTOR PERFORMANCE PROFILE REPORT The Head of Health Information Section initially explained the purpose for compiling performance profile reports, which is to monitor the performance of the selected indicators in the sector. These indicators include input, process, output and impact indicators. The presentation provided also the status of these indicators i.e. those that have been updated, are in the process of being updated and the ones that will not be updated because of incompleteness, lack of source or periodic collection. Updated indicators include DPT HPB coverage; proportion of births attended by trained birth attendants. The presentation was therefore based on Performance Profile Report (PPR) for 2006/7 prepared after the JAHSR The preparation of the PPR 2008 was still in progress due to incomplete information in existing systems (e.g. HMIS and PER). Main points from the presentation: On financial indicators the report recorded rising per capita expenditure over the years 2004/ /08. On-budget per capita spending on health increased from US$ 7.7 in 2006 to US$ 9.3 in The report showed no improvements in DPT HPB coverage and deliveries attended by trained birth attendants. In year 2007 the DPT3-Hb coverage was slightly lower (83 %) than the target of 85 % and the 87 % achieved for the year The reason explained were lack of funds allocated from the district to support supervision and lack of means of transport. Performance on skilled attended deliveries was found to be stagnant at 63% compared to 62.8% last year. This was later commented from audience to be of concern especially in the light of the focus on implementation of the Maternal, Newborn and Child Health One plan. Positive trends on malaria indicators compared to DHS data from were presented with increased coverage of IPT, ITN ownership and usage for pregnant women and under-fives and decline in incidence of fever in under-fives in 14 days previous to assessment. Overall downward trend in HIV prevalence from 7 to 5.7% was observed. On other indicators the Ministry is still collecting and validating information. The Ministry is planning to have a comprehensive presentation during the coming annual joint health sector review. STATUS OF MILESTONES The HSPS Coordinators from Health Sector Reform Secretariat (HSRS) presented the status of implementation of agreed Milestones: 1. Develop a Health Care Financing Strategy: A broad strategy for Heath Financing is part of the HSSP III, and it is envisaged that a detailed outline of the Strategy will be developed as part of implementation of HSSP III. 2. Develop Medium Term Strategy for Health Basket Fund: A generic document outlining the Medium Term Strategy for Health Basket has been completed and an MOU to the effect has been signed. 3. Increase enrolment in Pre service enrolment from 1,013 to 6,458 in 2008: The enrolment for all levels (certificate, diploma and degree) in public and private sectors has increased from 3,021 in 2007 to 3,831 in It is realized that additional support will be required, especially for FBO owned colleges (50% of health colleges in Tanzania), to increase enrolment to reach the ambitious goal in this milestone. 4. Develop/establish innovative mechanism for HRH retention, productivity & motivation: A P4P mechanism is in the process of being established in all 132 LGAs. In addition the Scheme of Service has been reviewed with Specialists being separated from General Practitioners, degree qualifications recognized in all cadres, and all cadres being included in Scheme of Service. Further a new salary structure for Health cadres is introduced; a mechanism for bank loans for health workers is progressing; and there is improved supply of medicines, working tools, buildings rehabilitation that makes the working place more satisfactory for many health professionals. 5. New Medicine Policy disseminated, new Drug Allocation Formula used: A new medicine policy was reviewed in line with Cabinet Secretariat guidelines and it is envisioned that a Master Plan for the Pharmaceutical Sector will be prepared after approval of Drug Policy. A report on development of an equitable Resource Allocation Formula for medicines and medical supplies has been submitted to MOHSW 6. Mapping of Public and Private providers by March, 2008: This exercise I ongoing in partnership with GTZ and other DPs TECHNICAL REVIEW MEETING page 6

7 7. Assessment of CCHPs: The exercise has been concluded and report disseminated to the meeting. LGAs have been asked, through PMORALG, to include within CCHPs, activities to address FBOs, CSOs, NGOs and P4P. 8. Roles and functions for RHMTs produced, explicit budget line for RHMTs in the RAS vote: The roles and functions for RHMTs, Regional Referral Hospital Management Teams and Hospital Boards developed; planning templates for Health Centers and Dispensaries have been developed; and TSh. 2.1 Billion has been allocated during 2008/2009 for RHMT Supervision to LGAs. 9. All Referral Hospitals have Annual Plans: All Referral Hospitals have developed Annual Plans from their Strategic Plans. However, these plans are usually not based on the Health Sector Strategic Plan, and for Regional Hospitals, these plans are not based on Regional Strategic Health Plans. 10. National PPP Steering Committee produces plans and budget for implementation of Service Agreement for approval by Technical Committee of SWAp: A plan was presented to last SWAp meeting in March The MOHSW has prepared a budget for implementing Service Agreements, and Zonal/Regional advocacy meetings were held. So far 3 LGAs have signed; but is must be admitted that there still exist lingering mistrust among both LGAs and private providers. 11. Operational Plan based on new M&E Strategy developed by December 2007: MOHSW 2007/2008 MTEF and POA were operational up to 30 th June, In addition the operational plan for 2008/2009 is based on a new M&E strategy. 12. Health Sector Annual Performance Report disseminated by August 2008: A verbal report will be presented to the Technical Review Workshop, and it is hoped that a draft report will be ready before JAHSR main meeting. 13. Capacity Development Plans to support ZTCs, RHMTs and CHMTs developed, MNCH Roadmap interventions developed: ZTHIs have been developed; MCH interventions are conducted as per Roadmap and reflected in CCHPs; LGAs have started EmOC in 50 HCs in selected districts; and some LGAs are upgrading HCs to address EmOC. 14. Nutrition Focal Points designated in all LGAs by March, 2008: The MOHSW has developed a Scheme of Service for Nutrition cadre. Following approval of the Scheme, together with other cadres, by PO PSM, MOHSW and PMORALG it is expected to post staff to LGAs. Initially, some existing health cadres will be reassigned to LGAs to perform nutrition related duties. 15. Work place HIV/AIDS programmes instituted throughout the system by Aug. 2008: An HIV/AIDS law has been passed and regulations are being formulated. MOHSW has developed and launched a costed Strategic Plan for the control of HIV/AIDS for HWs at work place (2006/2011). In addition, a training guide and facilitator s guide were developed and pre tested. DISCUSSION OF BOTH PRESENTATIONS ON MILESTONES AND SECTOR PERFORMANCE REPORT The World Bank (WB) highlighted that still no detailed strategy for Health Financing had been developed leaving milestone 1 unfulfilled. It was found that the HSSP draft strategy on health financing still had much room for improvement. MOHSW welcomed the WB interest and invited WB to actively contribute to the financing discussions during the group discussions and henceforth. Embassy of Ireland found it discouraging that some indicators were not reflecting progress in the sector, e.g. the skilled attended deliveries. The sector review should not be conducted before the performance profile report is ready; rather the JAHSR should be postponed. The representative mentioned that a number of the milestones were not fully met and some of the achievements had been meagre. The importance of integrating HSSP III indicators into existing HMIS was highlighted. The Head of Information Section, DPP, explained that some of the disappointing results could also be explained with certain statistical variations and use of inaccurate denominators. He invited programme people to explain particular questions regarding programme specific achievements. The EPI Project Manager confirmed the reasons given in presentation of lack of funds and means of transport. Additional Director HRD clarified regarding Milestone 3 on increase of the enrolment in pre-service training that the less than expected increase in enrolment should be seen in the light of the baseline that was already very high for the previous year. The DP Chair mentioned that some of the indicators presented were already updated with more accurate data. He also questioned that time was wasted on developing an M&E strategy; rather the Ministry should focus at implementation of a functioning M&E framework. The discussion also saw a need to take stock of indicators in reproductive health which does not show any improvement. We have to find out the factors leading to this position. Moreover, it emphasised the TECHNICAL REVIEW MEETING page 7

8 importance of completing the health facilities inventory and comprehensive report on the development of HIV/AIDs in workplace. The chair invited participants to continue the discussions also later during the Technical Review meeting. PUBLIC EXPENDITURE REVIEW 2007 The Public Expenditure review 2007 was presented by Head of Budget and Planning. The PER highlighted that FY08 budget health sector ranked third as a share of total government allocation. The PER had also noted a decline in central spending and increases in regional and district spending. The share was still below the Abuja target of a 15% allocation to the health sector of total Government budget. However in nominal terms there had been a budget increase of 24% compared to 2006/07. In contrast to FY2005/06 where the increase in the nominal allocation to the sector was due to PE component in FY2007/08 the increase was almost completely due to a 77% increase in the Development budget. The PER also illustrated that there was a shortfall of expenditure against budget, however a slight increase in overall budget performance, from 90% in FY2005/06 to 91% in FY2006/07 was realized. There was a significant fall in the execution of the development budget over the year, from 98% to 84%. Concerning budget allocation to the different levels over the past 4 years there had been a trend of decreasing budget allocation to central level as opposed to an equivalent increase in budget to LGA and regional level. The meeting expressed a need for the Ministry to commission the next PER since time for budget guidelines were approaching being by the end of September SUMMARY COMPREHENSIVE COUNCIL HEALTH PLANS Salient points extracted from the presentation. The plans show substantial improvement from the past plans and reports. However, continuous improvement is necessary in terms of fine tuning on specific weaknesses. There is a need to continue capacity building of the RHMTs, CHMTs and the Centre. CHMTs and RHMTs staff turnover rate is too high to sustain quality performance. Most of the staff in the Council Health Management Teams is in acting positions, leaving them uncertain of their status and hence lacking confidence. The new staff in place have not been initiated or trained on planning for district health services. This demands more training and capacity building, either through tailor made on job training and intensive supportive supervision. There is a need to build capacity of RHMTs and CHMTs to be able to use the PlanRep tool correctly. Planning teams should be advised on the type and relevance of information to be attached from PlanRep to ensure uniformity, validity, reliability and comparability and quality improvement of the reports. CHMTs should be trained through technical backstopping and supervision to improve their plans, specifically on executive summaries, formulation of targets, activities, updating of performance indicators and inclusion of appropriate Essential Health Package items. This special task can be outsourced to the Zonal Health Resource Centres with a back up team of planners and RHMTs after training them. Or for sustainability be outsourced to our higher learning institutions on short course mode. Capacity building for report preparation should focus on performance, accurateness, consistency of information and timeliness. Performance indicators should be followed up to ensure their accurateness, completeness and usefulness for planning and monitoring. The criteria assessment tools should be revised to focus more on the contents relating to burden of diseases or priority district health problems. Discussions on PER 2007/8 and CCHPs The PER report was found to have many gaps. The steering group for the process has not been functional and not fully met their TORs e.g. the survey in the Councils has not taken place. The meeting found a need to outline what can be done for future PER. The meeting was also concerned with gaps in information from external funding from Ministry of Finance and claims out of NHIF. The audience directed their attention towards unspent health services funds and called for immediate action to address the problem based on studies that have looked on the factors leading to this situation. Concerning the CCHP report the reflected improvements in CCHP quality need to be compared with the previous CCHPs. With regards to the poor implementation due to the delay of funds, it was advised that Councils plan accordingly since based on experience they should be aware that disbursement of funds is delayed. One of the challenges presented for the CHMTs is staff being in acting position for a long time, it was advised that the government develop succession plan to avoid this problem TECHNICAL REVIEW MEETING page 8

9 GROUPWORK WEDNESDAY 3 rd AFTERNOON Performance Assessment Report Group: The group discussed the background of performance assessment report which is meant to meet the need for evaluating the health sector strategic plan. About 33 indicators were discussed in the group. They found the challenges for performance assessment report to include; Source of information performance of HMIS, problems in accessing NACP, and TB/L data. However an opportunity does exist such as EPI Program annual meetings. In the group it was learnt that as part of the existing opportunities there are still indicators which has not been processed. The Ministry promised to complete them before the forthcoming JAHSR. Suggested milestones by the group: Strengthen HMIS systems based on HSSP III sector indicators Strengthen M&E unit to be able to contract TA Dissemination of performance assessment report to parliament, regions and districts It was recommended that the milestones could be slightly more specific. Milestones Group presentation Thursday 4 th morning. The group had assessed and revised the progress report on the milestones. The updated progress report on the 2007/08 milestones can be found as annex 1. In particular milestone no. 7 regarding CCHPs was discussed. The issue of including the CSO/FBO and private-for-profit sector activities in the CCHPs will be complicated. Public Expenditure Review Group: The group discussed whether PER is still needed by MOHSW. The Ministry pointed out that it is still needed to monitor health expenditures within the sector as well as its share of the total government spending. PER should be conducted annually and the capacity and organization of the responsible section in the Ministry should be reviewed. The PER assists the Ministry in the identification of priority areas which should be included in the national budget guidelines. The group agreed to change the timing of undertaking PER from September December to March-June, This will resolve the problems of getting data from different sources. Suggested milestones The Ministry should develop a plan to institutionalise PER with the policy and planning department. A point core team of not less than three staff in MOHSW to work on PER with a focal point. HEALTH SECTOR STRATEGIC PLAN III ( ) The HSPS Coordinator initially described the Health Sector Strategic Plan (HSSP) III planning process that had taken place since the JAHSR The draft 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 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 TECHNICAL REVIEW MEETING page 9

10 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 central 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 necessary to keep health workers updated. Training institutions will increase their production by higher numbers of graduates and will improve their quality through update of the curricula. Strategy 5 Health Care Financing, is fundamental for realising the ambitions of the MOHSW. The Ministry aims at increasing the health budget to 15% of the Government budget. Increasing the funding through the Health Basket Fund is a way of resource mobilisation. A detailed Health Financing Strategy will be developed. The Ministry will develop strategies to increase complementary financing through the Community Health Fund and National Health Insurance Fund. The management of these funds will improve and a regulatory body for health insurances will be created. Increased collaboration with the private sector will open up opportunities for investments in health. Strategy 6 focusing on Public Private Partnerships will be important for achieving the goals of the health sector. PPP forums will be installed at national, regional and district level. The Service Agreements will be used in all LGAs to contract private providers for service delivery. The private training institutions will be more involved in production of HRH, based on their specific competencies. Strategy 7 aim at improving Maternal Newborn and Child Health as result of general measures like increasing the number of primary health facilities, increasing the number of competent staff and improving equipment and supplies in health facilities. A better referral system will increase access to emergency obstetric care. The communities will be more involved in MNCH to improve behaviour and practices with regard to reproductive health. Strategy 8 concerns the various disease control programmes which will equally benefit from general improvements in health facilities. The diagnostic capacity (in labs) will improve and equipment and supplies increased. The TQIF will stimulate further introduction of treatment guidelines and clinical standards. The HIV/AIDS programme will continue with increased access to ARV treatment to PMTCT and Post Exposure Prophylaxis. Prevention and Voluntary Counselling and Testing will be stimulated, as well as treatment of sexually transmitted diseases. All hospitals will guarantee safe blood transfusions. In the malaria programme vector control through Insecticide Treated Nets and Indoor Residual Spraying will be stepped up. The adequate diagnosis and treatment will be further expanded. In the tuberculosis programme the DOTs strategy will continue, while vigilance for Multi Drug Resistant TB will be high. The leprosy control and disability prevention programme will be implemented in all districts. There will be more attention for neglected diseases, even if they have only regional importance, by training of staff and provision of medicines, to reduce unnecessary suffering and death. Non-communicable Diseases become more and more important with the shifting demographic situation. More attention for healthier lifestyles, disease prevention and better treatment will be stimulated. With regard to environmental health, the focus is on implementing the new Public Health Bill, and on introducing adequate measures for adherence to the legislation TECHNICAL REVIEW MEETING page 10

11 Strategy 9 - Emergency Preparedness and response - is a new theme in the strategic plan, but important due to globalisation health threats that may come up unexpectedly. Capacity building at all levels is planned to deal with emergencies or prevent them. Quick mobilisation of resources will be realised, when needed. Strategy 10 focuses on Social welfare which is introduced as a new and challenging theme in the HSSP. The capacity has to be built in all districts to provide social welfare and protection services. The regulatory framework has to be developed and community-based programmes have to be initiated or strengthened, shifting from a charity approach to a rights-based approach. Strategy 11 on Monitoring & Evaluation will help to improve evidence-based decision making and to enhance public accountability. The Ministry will develop a comprehensive M&E and Research policy and strategy, to ensure that more integration and harmonisation will be achieved. Integration of the MOHSW monitoring systems with the PMO-RALG and MKUKUTA systems will be achieved. The Health Management Information System will be revisited. At national level there will data warehouses, where information from several sources is merged, and used for further analysis. The HSSP III also consider a large number of equally important health sector issues including capital investments; medicines and medical supplies; and cross cutting issues including general quality improvement; equity; gender, community involvement; inter-sectorial collaboration among others. Also the Management, financing and information systems in the sector is highlighted in the strategic plan. The process foreseen before the new strategic plan is launched in July 2009 was further explained. Presentation on HSSP III M&E Framework and use of indicators: The list of proposed indicators include MDG, General budget support, MKUKUTA, HSSP II and CCHP indicators. They have taken care of the availability and source of the information e.g. routine data system, Census and Surveys, Surveillances, Evaluation, Vital registration and special studies/research. Local government have actively participated in the identification of relevant indicators which should be harmonized with the LGA monitoring system to the extend possible. However, the indicators to be used for HSSP III need to be furher refined and finalized. A task force including wide representation of stakeholders volunteered for this assignment. PLENARY DISCUSSION In the light of the Human Resource Crisis and repeated positive impact of Community Health Workers on health it was suggested that these should be mentioned as part of the community strategy. Elements of management issues should be incorporated in the HSSP III and clear lines of feedback from MOHSW or PMORALG on plans provided by regions and districts should be outlined. The custodian role of the MOHSW to oversee, analyze and act on developments in the sector was pointed out not to be clearly reflected in the document. The document should reflect the roles of the MOHSW and other stakeholders and actors in the health system. It was further asked what health sector status was expected at the end of the plan and it was suggested that clear operational targets should be develop It was also suggested to include a short introductory section on vision for where the health sector should be in Disappointment was expressed that there was no mention of vision, mission or clear goals; no reference to client-service charter; and no mention of implementation of allocation formula in pharmaceutical section. It was furthermore suggested that there should be more reference made to the Joint External Evaluation, and the connection between chapters 4 and 6 should be clearer. Some members expressed that nutrition and malnutrition was insufficiently reflected in the document. It was highlighted that the MNCH strategy should clearly reflect that more focus should be given to increase skilled births attendance, EMOc and family planning and the document should look at mothers beyond pregnancy and into the post partum period. Also a reference to the P4P scheme and its relation to MNCH should be made. A concern on how to link the African Union MCH plan with the reproductive health road map was raised. Tanzania is signatory on a large number of international programs including ICPP and it was raised that young people should be given more prominence in the strategy. For PPP it was raised that focus was only on service delivery level. It was suggested that partnership with the industry providing commodity services should link chapters 6 and 4. Also a need to mainstream and link PPP between different chapters was expressed. Concerning HR crisis the public sector should partner more with the private sector. On Social Welfare UNICEF mentioned having a section working on strengthening Social Welfare, from which they would provide the latest report. A strategy to counter the dramatic shortfall of social workers should be included. It was suggested that a plan for the MOHSW to improve the vital registration system should be included, since many outlined indicators could be picked from such a source. The strategic intervention to ensure that TECHNICAL REVIEW MEETING page 11

12 HMIS and information is better used at district level should also be reflected in the document..a question was raised on the link between the extensive list of indicators in chapter 6 and the list of indicator at the end of the document. It was recommended that replicability and SMARTness of indicators should be taken into consideration. It was mentioned that in the presentation of the HSSP III reference was made to a detailed Health Financing strategy but one such appears not to exist. It was suggested that the HSSP III should indicate what proportion of available resources should be allocated to different levels of the health system. It was raised that the expected resource need for the duration of the HSSP III (table) was fluctuating without any adjacent explanation. Due to the burden on the health system it was suggested that trauma should be considered as a separate strategy. Concerning Council and Regional level the importance of ownership of the HSSP III it was highlighted and suggested to be more prominent in the document. Concern was raised that more responsibility is planned to be devolved to lower levels but there is no indication of concurrent increase in resource allocation to these levels. Plans to increase health care finance allocation to local government should be reflected in the documents. A desire for a more general, bold vision for the health sector was expressed e.g. what will the role of service agreement be for both public and private sector by 2015? What will the role of MOHSW vis-a-vis the training institutions be by 2015? Should a directorate for M&E and Health Financing be a vision? A general caution was mentioned to reflect on whether this plan is achievable especially when compared to how much has been achieved of the HSSP II. Private institutions get less than 13% of entire health budget but recent reports have shown that poor people use the private health facilities more than rich people. A cost sharing strategy (e.g. by including the private sector in the CHF) with private sector is needed in order to provide services to the poor. To maximize usage of resources the Service agreement should assure that no building of facilities would take place where private facilities are already operational. Comments to M&E presentation The list of HSSP III indicators should reflect the responsible partner for the collection of the data. With better harmonization of indicators the number could be reduced. The system should be linked to other M&E systems, e.g. PMORALG, to avoid duplication and reduce transaction cost. It was suggested that like analysis for some indicators is done by age group disaggregation based on gender should also be introduced. A caution to use annual existing indicators instead of creating a need for annual special surveys was given. It was also noted that no indicators for cross cutting issues had been included. It was also suggested to add a column in the matrix indicating the responsible person or organization for data collection. HSSP III FINANCING GROUP PRESENTATION The main findings presented from the group work were: Overall there was a concern that some of the comments from the Health Financing HSSP Planning Group retreat have not been incorporated in the Draft HSSP III document. These includes the fact that the HSSP III will seek to develop a comprehensive health financing strategy. A need to strengthen the capacity in the Ministry of Health and Social Welfare to undertake costing studies, Public Expenditure Reviews and National Health Accounts was expressed. The detailed Health Financing Strategy will expand on the vision and future developments in the health sector financing. It was suggested to keep this as a milestone for year 08/09. Involvement of the private sector needs to be reflected more clearly in the HSSP III strategy 5. Also a need was expressed to put in place an appropriate mechanism to capture financial information in the health sector (National Health Account tool) for showing revenue generated from different sources, how the revenues are allocated and whether allocation formula is appropriate. Expenditures should be clearly reflected. Comments to the presentation: More specific targets related to allocation of resources is needed. A question concerning the Service agreement was raised on the intentions by 2015, whether this is intended to be a tool for both private and public sector. With regards to the financing of HSSP III the group recommended to break down the resource envelope by sources using PER reports and if possible to categorise proposed future spending between recurrent and development expenditures. It was decided that a group will meet to assess the first retreat output against what is in the HSSP III document to identify any possible major omissions TECHNICAL REVIEW MEETING page 12

13 HSSP III MONITORING & EVALUATION GROUP PRESENTATION M&E group presented the following main priorities: Chapter on M&E strategy in HSSP III: Strengthening of vital statistics should to be included as a priority as well as strengthening of the HIR section to coordinate all data collected in the sector. However, the responsibility for carrying out the vital statistics monitoring system does fall under the Ministry of Justice and National Bureau of Statistics and not the MOHSW. WHO will with the Health Metric Network project assist with the development of vital statistics reporting in Tanzania. The group found that the MOHSW Health Information Section was understaffed, and suggested that the section be upgraded. Concerning the proposed indicators in the HSSP III, the group found that the suggested 59 indicators are far too many and the quality of these indicators should be reviewed. There is a need for solid baseline data and more specific targets indicators for cross cutting issues need to be included. A meeting was planned to further assess the proposed indicators for the HSSP III. Suggested Milestones: 1. Secure funds and start implementation of the proposal for strengthening HMIS by the beginning of the 3rd quarter of the finacial year 08/09. Responsible person DPP. 2. Strengthen the HIR section of the MOHSW by providing it with skilled staff and equipment in order to competently perform the functions described in 3 above by the second year of HSSPIII implementation. Responsible persons DPP and CMO. HSSP III HUMAN RESOURCES GROUP PRESENTATION Main concerns presented from the HR group work were: How can actors and DPs supporting HR in the HSSP III be harmonized? The issue of task shifting must be mentioned in the HSSP III, i.e. maximising skills of health workers and give increased attention to remote areas including establishing incentive mechanisms. Importance of Community Health Workers should be included in HSSP III and there should be comprehensive harmonization and coordination of training managed through DHR. It should be explored whether there is a need for an additional HR structure for coordinating HR issues between different sector stakeholders like MOHSW, POPSM and PMORALG. Also some specific changes of wording were proposed for the wording of HR related issues in the chapter 6. PAYMENT FOR PERFORMANCE P4P Presentation of P4P: The need for P4P emerged because of the prevailing high maternal mortality rates despite the increased funding to the area. It is anticipated that motivating staff may improve performance and have direct possitive effect on maternal mortalities. The basket fund has increased its allocation to 1 US$ per capita to accommodate P4P. The circular for implementation of the P4P was sent to all authorities at different level of the government and the concept has been included in the government budget. The proposed amount to be given to health facilities at different levels was provided which ranges from Tshs 10 million to Tshs 1 million. These figures have been used for budgeting purposes. The performance indicators that will qualify for P4P were outlined these being immunization coverage of DPT3, skilled attended deliveries, IPT for pregnant mothers, provision of ITN and timely MTUHA reporting. All the indicators will be given equal weight. The allocation is suggested to be bi-annually but a specific guideline for the intervention is still to be developed. The implementation of P4P is coordinated in the Directorate of Policy and Planning. The implementation timetable was presented starting in September 2008 and ending in August 2009 with an evaluation report of its performance TECHNICAL REVIEW MEETING page 13

14 PLENARY DISCUSSION It was raised that the timetable is ambitious and that approval to allocate funds from the basket has not been granted yet. There were expressed concerns on the sustainability of the program since it relies on donor support. It was clarified that the increase of the health basket fund from US.75 per capita to US $ 1 per capita had been decided even before the P4P scheme was introduced. However, the increase was intended to reward Councils who are performing better. It was insisted that the implementation framework should be simple and the importance of a timely implementation framework and guideline was emphasised as a prerequisite to implementation of the programme. The question was raised on what has been done to avoid perverse actions in the health facilities including cheating with information to become eligible for the additional funds. More clarification on the development of the indicators and on how long time will donors continue to support P4P were requested. IT was suggested to start the program as a pilot activity, and then expand after learning from experience. Also is was asked whether there are plans to include other performances (than MCH) in the P4P scheme in the future. The Troika Chair explained again the development of the P4P which should act as incentive at the facility level. However, the development of the concept got confused and the concept was launched without keeping all stakeholder informed. The Troika Chair identified some flaws in the concept as it was being implemented, and suggested that perhaps the FY 2008/9 should be used to clarify the concept. It was explained that the process of developing the P4P concept had been done through consultations during several meetings. The risks of launching the scheme was well known and understood, but it was important to initiate the P4P initiative, and some of the ambiguous issues would be made very clear in the guidelines expected to be completed by the end of September. The comments at the Technical Review would also inform the development of the guidelines which should be made simple and comprehensive at the same time. The revision of the HMIS registries has improved and will help ensuring a successful launch of the P4P concept. Quarterly payment was considered not to be feasible, but half-annual or annually would be possible. With respect to questions regarding the sustainability of the new P4P concept, the Ministry trusted that P4P can continue at least as long as basket funding exists. Only public and FBO health facilities is initially being included, but it is not fixed; hence private facilities may also be covered in the future. Remaining money at the end of FY 2008/9 may be used to areas beyond the MCH activities that are the primary focus of the initial P4P activities. The chair completed the session by highlighting the importance of the P4P scheme. DRAFT NCD STRATEGY Presentation by Director DHS with the following main points: Due to increasing morbidity and mortality caused by NCD a National Strategy for NCD has been drafted for the prevention, control and treatment of NCDs in Tanzania (Mainland). According to the Adult Morbidity and Mortality Program NCD account for between % of all Years of Life Lost in Tanzania. NCDs include: cancers, chronic respiratory diseases, cardiovascular diseases, diabetes, mental disorders, substance abuse, sickle cell disease, injuries and trauma. Strategy Goal: To reduce the disease burden from NCDs by taking integrated action as to have a society with good health free of NCDs contributing effectively to individual and national development General Objective: To combine integrated action on NCD risk factors and their underlying determinants, and strengthen health systems so as to reduce the NCD morbidity and mortality The NCD strategy focuses on the 3 levels of prevention ie primary, secondary and tertiary. Primary prevention will include awareness creation at all levels, Health Promotion aiming at reducing common risk factors like unhealthy diet, physical inactivity and tobacco and alcohol consumption. Strengthen NCD planning through inclusion in existing M&E system and relevant research. Secondary prevention: Strengthen Health workers capacity to identify, manage and rehabilitate NCD patients. At all levels ensure availability of relevant equipment and medicines and develop and implement screening programs. Tertiary prevention will focus on strengthening of programs of home based care of chronically ill and rehabilitation programs to strengthen palliative care. In the line with the Medium Term Strategic Plan of the MOHSW, this Strategy will aim to provide and promote equity by ensuring access for all to quality NCD services throughout the country, integration in existing health system avoiding verticalization, Evidence based approach implementing cost effective interventions adapted to the Tanzanian context and multi-sector approach involving all relevant stakeholders from public, private, civil society and international stakeholders and linkage to relevant communicable diseases. Monitoring and evaluation are essential in ensuring optimal planning and NCD indicators should be included in routine monitoring and evaluation TECHNICAL REVIEW MEETING page 14