the role of governance in health systems


Rent-seeking behaviour, quality of care and health systems governance: the role of supervision, Health Facility Governing Committees and non-financial incentives in Tanzania.

Setting

Rationale

 

Objectives and approach

Tanzania

Despite its great importance for the universal provision of quality health services, health systems governance is a rather elusive concept, difficult to define and operationalize. Some important operational dimensions of health systems governance are represented by regulation, guidelines, supervision, and incentive policies for health professionals. The extent of supervision and auditing activities in health systems varies across and within countries. The emergence of rent-seeking behavior builds on these failures, exploiting gaps in regulation, monitoring and supervision to abusively extract private gains, negatively affecting service quality and ultimately patients’ health. Financial and non-financial incentives can potentially be effective in alleviating these negative outcomes, aligning health workers’ incentives with the public interest.

 

This study aims at assessing quantitatively the association between measures of supportive and administrative supervision (in terms of their intensity and effectiveness), Health Facility Governing Committees (HFGCs) activities and different non-financial incentives to health workers, with measures of rent-seeking behavior and of quality of care. The study is based on a sample of public health facilities in Tanzania surveyed by the Service Provision Assessment surveys in 2014/2015 and in 2006. The analysis employs different regression techniques, taking into account the multilevel structure of the data that reflects the country’s decentralized health system organization.

 



Impacts of the regional complementary pharmaceutical supply system in Dodoma region, Tanzania

Setting

Rationale

 

Objectives and approach

Objectives and approach

Objectives and approach

Objectives and approach

Tanzania

Availability of quality medicines in the provision of health care service is an integral part of universal health coverage (UHC). Medicines are essential for health care service delivery and accounts for a high proportion of government and household expenditure. Countries have been undertaking various health financing reforms including promotion of health insurance schemes and increase in the amount of budgets allocated for healthcare in order to address cost of medical supplies. Furthermore implementation of public-private partnership has been strengthened so as to improve access to quality medicines and pharmaceutical services in underserved areas. In Tanzania the medical stores department (MSD) has been responsible for supplying medical products to the public health facilities. However, order fulfilment rates from the facilities is about 60%. Recently the regional authority and district councils in Dodoma, Morogoro, and Shinyanga regions started implementing a complementary pharmaceutical supply system funded by Swiss Agency for Development and Cooperation (SDC) through the Health Promotion and Systems Strengthening (HPSS) project known as Jazia Prime Vendor system (PVS). The aim is to improve availability of medicines of good quality.

 

 

1. Effects of medicines availability and frequency of stock-outs on health care seeking behaviour, health insurance membership retention and trust to the health workers 

The objective of this study is to assess the effects of medicines availability and frequency of stock-outs on health care seeking behaviour, health insurance membership retention and trust to the health workers by taking Jazia Prime Vendor system (PVS) as a case study. We will use the HPSS data collected in the baseline and end-line surveys conducted in 2012 and 2017 respectively. Descriptive statistics will inform the variables (covariates) to be included in regression models. In all the analysis we will adjust for facility level clustering and regressions will be subjected to diagnostics identifying observations of outlier, leverage and influence. 

2. Effectiveness and challenges of existing governance and accountability structures in procurement, distribution, storage and dispensing of medical commodities

To understand existing governance and accountability structures in procurement, distribution, storage and dispensing of medical commodities as well as their effectiveness in addressing stock-outs within the PV system we will review any reports held by the HPSS, district level managers relating to the availability of medical supplies within the study area. Furthermore we will conduct in-depth interviews with national key informants, including the managers of the NHIF, the CHF/TIKA coordinator, stakeholders at the MoHCDGEC, and Medical store department (MSD) with considerable influence in the supply of medical supplies in the districts/facilities. A series of in-depth interviews will also be carried out with health facility governing teams (HFGT); in-charges of health facilities and CHF beneficiaries.

3. Management and financing challenges to implement  the Prime Vendor system in Tanzania 

The aim of this study is to assess the extent to which existing management and financing procedures/structures support or impede the PV system, and document changes made to the management system as a result of the Jazia PVSA. Qualitative approach will be used, whereby a series of in-depth interviews will be conducted at the regional, district and health facility level to document existing official management structures relating to the PV system and any possible changes which were made during its establishment or for future improvement.  We will look at the flow of the funds to and from different sources and pooling mechanism in place. To understand the relative contributions of CHF funds to the overall health resource envelope, if possible we will also compile overall financial flows to districts (inclusive of basket and block grants). We will interview the facility accountants to assess what proportion of funds claimed that were received and the average time from request for funds to receipt of funds.  We will also ask about decision making on how funds received were used within the facilities and community involvement in managing the resources.

4. Costs of setting up the Jazia prime vendor system in Dodoma and Morogoro and resources implications  of rolling it out in the whole Tanzania

The objective is to estimate costs and costs drivers for setting up prime vendor system in the districts and model the costs of the role out of the Jazia PVS in other regions and councils in Tanzania. This study will be carried out from a societal perspective, which includes all agencies or bodies that are involved in implementation or who incur costs as a result of the implementation of PV system. Resources will be valued at their opportunity cost, or the value of the benefits forgone by using resources in one way rather than another. We will estimate the costs of implementing PV system and model costs for the scale up to other regions in Tanzania, If possible will compare PV implementation costs to the previous system. A series of one way sensitivity analyses will be undertaken to assess the effect on results of variations in key parameters.



The impact of social accountability mechanisms on social health protection: the case of Tanzanian region of Dodoma

Setting

Rationale

 

Objectives and approach

Tanzania

Social accountability mechanisms are increasingly popular health systems governance tools. Representatives of the community are typically involved in oversight over financial management of local public health facilities and they cooperate with patients in monitoring service quality. Implementation projects based on social accountability mechanism have been rolled out in several low income countries with the support of development partners and local NGO’s. A notable example in Tanzania is the Social Accountability Monitoring (SAM) program run by Sikika, a local NGO with the core goal of catalyzing improvements in health service provision in the country. Yet, the evidence on the effectiveness of social accountability mechanisms is still inconclusive. Some studies point at modest short-term improvements in health outcomes, whilst other studies are more skeptical about the effectiveness of these interventions.

 

This study aims at evaluating the impact of Sikika’s social accountability initiative implemented in the Tanzanian region of Dodoma since 2012. Using the baseline (2011) and endline (2017) surveys collected by the Health Promotion and System Strengthening (HPSS) project for internal evaluation purposes on a large sample of health facilities in the region, we aim at evaluating the impact of SAM on different dimensions of health service delivery using a quasi-experimental design study. The health facilities in the two districts where Sikika is active represent the treatment group, while the health facilities in other districts in the region will serve as control group. To estimate the effect, we will employ quasi-experimental econometric techniques.

 



Mapping patterns of district level health system governance network structure. Implications for social health protection and health systems performance in Tanzania

Setting

Rationale

 

Objectives and approach

Tanzania

The organizational design and governance structures can be viewed as the nonphysical infrastructure of the health system. For firms and other organizations, corporate governance and organizational design play a key role in shaping incentives and functioning of the organization itself. Health systems are complex and fragmented organizations. As such, in general, poorly designed health systems with loose governance structures will hardly produce good performances. Organizational and governance structure design includes (but is not limited to) the definition of hierarchical relationships, responsibilities and decisional independence (over budget spending for example), accountability chains, decision making chains, centralization/decentralization of certain functions, etc.

Nevertheless, in all sorts of organizations, real life organizational and governance structures often differ from what is formally prescribed by rules or organizational charts. Differently realized structures can potentially give rise to diverging outcomes (positive or negative), resulting from differences in channels and frequency of communications, decision making chains or simply from different characteristics of key people in the organization.

 

The goal of our study is to understand how informal governance structures in district health systems differ from formally prescribed structures and, notably, the implications of these differences as well as the interactions of social connectedness with performance in service delivery. To that end, specific primary data will be collected in two districts for all actors in the public health system, focusing on three thematic areas: child care, treatment of NCDs and administrative matters. The data collection and analysis is based on a social network analysis (SNA) approach. SNA turns out to be a powerful tool to map the governance structure in district health systems, analyze relational data and social structures and study the interaction between social networks and health service delivery.