Masuma Mamdani , Ifakara Health Institute

Applying a Governance Lens to Assess the Health Systems:

Maximising Access to Essential Health Interventions. A Focus on Tanzania

Masuma Mamdani, Ifakara Health InstituteRegional Summer School Governance for Health Systems

Development –Convened by SOAS, University of London in association with IDS, University of Dar es Salaam, 18th-22nd July,

2011. Movenpick Hotel, Dar es Salaam

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What is Governance?

Process of decision-makingProcess of decision-making and how they are and how they are implemented/ not implemented. Focuses on:implemented/ not implemented. Focuses on: formal and informal actorsformal and informal actors involved in involved in

decision-making and implementing decision-making and implementing formal and informal structuresformal and informal structures that have been that have been

set in place to arrive at and implement the set in place to arrive at and implement the decisiondecision

Source: WikipediaSource: Wikipedia

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What is Good Governance?

“…“….an ideal which is difficult to achieve in its .an ideal which is difficult to achieve in its totality….to ensure sustainable human totality….to ensure sustainable human development, actions must be take to work development, actions must be take to work towards this ideal with the aim of making it a towards this ideal with the aim of making it a reality” UNESCAPreality” UNESCAP

“““….is important in ensuring effective health care is important in ensuring effective health care delivery, and that returns to investments in health delivery, and that returns to investments in health are low where governance issues are not are low where governance issues are not addressed.” addressed.” Maureen Lewis, “Governance and Corruption in Public Health Care Maureen Lewis, “Governance and Corruption in Public Health Care

Systems” CGD Working Paper 78, Jan 2006Systems” CGD Working Paper 78, Jan 2006

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What is a Health System?

Complex, dynamic and ever changing.

not static Many issues affect the ability of health systems to

deliver - governance, financing, HR, information, access, quality, impacts of reforms in other areas of the economies significantly, etc.

Many actors are involved – government, ministries, CSOs, financing agents (global, national), service providers, communities, etc …their perspectives of the system vary.

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Improving a health system has become a balancing act…..

Decision makers: the need for disease specific programmes vs. those

targeting the health system as a whole;

national priorities with global initiatives;

policy directives with “street-level” realities

“the context”

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Central question: efficient use of available resources towards improved health

outcomes for ALL

Beyond the Health Sector

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Central question: efficient use of available resources towards effective access to

essential life saving health services for ALL

A Focus on the Health Sector

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Tanzania’s total health sector budget increased by 37% (nominal terms) from 2006/07 to 2007/08 (PER & MTEF, MoHSW)

Est. annual/capita Est. annual/capita spending on health spending on health (USD, nominal):(USD, nominal):

6.8 - FY066.8 - FY06 10.3 - FY0710.3 - FY07 13.8 - FY0813.8 - FY08

Est. health exp. of total Est. health exp. of total govt. exp.:govt. exp.:

9.7% FY069.7% FY06 10.3% FY0710.3% FY07 10.5% FY0810.5% FY08

Falling short of Abuja Falling short of Abuja target 15%target 15%

Excludes significant ‘off Excludes significant ‘off budget funding’budget funding’

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Distortions……

““Aid [for HIV/AIDS] increased by three-quarters Aid [for HIV/AIDS] increased by three-quarters and now finances 95% of Government plus donor and now finances 95% of Government plus donor spending. The increase has been from off-budget spending. The increase has been from off-budget sources of finance, and only 19% of expected aid sources of finance, and only 19% of expected aid in 2007/08 is included in the budget. HIV/AIDS is in 2007/08 is included in the budget. HIV/AIDS is now taking a staggering one-third of all aid to now taking a staggering one-third of all aid to Tanzania” (IMF ODA data, TACAIDS 2008).Tanzania” (IMF ODA data, TACAIDS 2008).

Implications for national planning and budgeting? Implications for national planning and budgeting? Of establishing a clear link between strategic Of establishing a clear link between strategic plans, approved budgets and actual expenditures plans, approved budgets and actual expenditures against goals and targets?…GOVERNANCE?against goals and targets?…GOVERNANCE?

How have and will GHIs shape the system How have and will GHIs shape the system (HIV/AIDS, malaria, GAVI)?(HIV/AIDS, malaria, GAVI)?

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Health Sector Reforms

Introduced in the 90s in response to worsening Introduced in the 90s in response to worsening situationsituation

Financial sustainability is a key component of the Financial sustainability is a key component of the reformsreforms

Cost Sharing: Cost Sharing: Generate RevenueGenerate Revenue Improve Quality of CareImprove Quality of Care Enhance EquityEnhance Equity Reduce frivolous consumptionReduce frivolous consumption

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Who pays for health care in Tz (2005/6 figures)? Donor funding - grants/loans - direct or through

SWAp/ GBS, 45%

General tax revenue -28% - relatively progressive

Out-of-pocket payments (OOPs direct payments to health care providers - 23% - very regressive

Health insurance contributions - less than 10% of the population - mix

Government provides a basic package of public preventive health services for ALL; minimal financial protection for the most vulnerable

Source: SHIELD Project (IHI 2010), quoting Tanzania National Health Accounts 2005/06,

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How many people are covered by HI in Tanzania?

9% in 2008 (SHIELD data)9% in 2008 (SHIELD data) 13% in 2011 : NHIF (5.8%), CHF (6.6%), other 13% in 2011 : NHIF (5.8%), CHF (6.6%), other

schemes (1%) (NHIF data)schemes (1%) (NHIF data) Intention to increase HI coverage to 45% by 2015Intention to increase HI coverage to 45% by 2015

Source: Borghi j and Joachim A. 2011. Who is covered by health insurance schemes and Source: Borghi j and Joachim A. 2011. Who is covered by health insurance schemes and which services are used in Tanzania? SHIELD Project. IHI, Tanzania.which services are used in Tanzania? SHIELD Project. IHI, Tanzania.

SHIELD website: http://web.uct.ac.za/depts/heu/SHIELD/about/about.htm

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HI coverage is highest among the better-off working in the formal sector ….

In 2008, 12% of the richest groups were insured In 2008, 12% of the richest groups were insured compared to 4% of the poorest groups compared to 4% of the poorest groups

Better off: mainly NHIF, some private and CHFBetter off: mainly NHIF, some private and CHF

Poorest: all CHFPoorest: all CHF

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The poor pay a higher proportion of their income than the rich.

Contributions to the NHIF are the most progressive, but only constitute a small amount of total funding (3%) & benefit those who contribute (generally better off, small proportion of the population).

Tax funding is the second most progressive source of financing, benefits may be enjoyed by everyone (44%).

Out-of-pocket payments represent the largest component of household contributions to health care financing, highly regressive (53%)

Contributions to CHF are minimal (0%), regressive, majority of members are poor, flat rate

IHI. 2010. Who Pays for Health Care in Tanzania. SHIELD ProjectIHI. 2010. Who Pays for Health Care in Tanzania. SHIELD Project HBS data 2000/01

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But the rich benefit more than the poor……..

The poorest 20% receive less benefit than they need.

Benefits from outpatient and inpatient care in public hospitals, and private facilities are pro-rich.

Benefits from faith-based facilities are generally evenly distributed

Source: Source: IHI. 2010. Who benefits from health care. SHIELD Project).IHI. 2010. Who benefits from health care. SHIELD Project).

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The poor consume less health care, in spite of greater need

Compared to poorest quintile, the top quintile are:Compared to poorest quintile, the top quintile are: 3.4 times3.4 times more likely to use modern contraception more likely to use modern contraception 2.8 times2.8 times more likely to have skilled attendance at delivery more likely to have skilled attendance at delivery 8.7 times8.7 times more likely to have a C-Section more likely to have a C-Section 7 times7 times less likely to give birth at home AND have no less likely to give birth at home AND have no

post-natal carepost-natal care 40%40% more likely to have measles vaccination more likely to have measles vaccination 40%40% more likely to receive treatment for fever at a health more likely to receive treatment for fever at a health

facilityfacility 20%20% more likely to receive any ORS for diarrhoea more likely to receive any ORS for diarrhoea 14 times14 times more likely to have slept under an ITN the more likely to have slept under an ITN the

previous nightprevious nightSource: Paul Smithson. 2006. Fair’s Fair. Health Inequalities and Health Equity in Tanzania. Prepared for Source: Paul Smithson. 2006. Fair’s Fair. Health Inequalities and Health Equity in Tanzania. Prepared for

Women’s Dignity Project. IHI, Tanzania.Women’s Dignity Project. IHI, Tanzania.

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Barriers to effective access by the very poor Real costs of treatment (out of pocket): Real costs of treatment (out of pocket):

Drugs often greatest cost, than transportDrugs often greatest cost, than transport ‘‘Unofficial’ or ‘under-the-counter’ feesUnofficial’ or ‘under-the-counter’ fees

Inflexible modes of paymentInflexible modes of payment Ineffective exemption system for those too poor to Ineffective exemption system for those too poor to

pay – exclusionarypay – exclusionary Indirect costs (productive time lost)Indirect costs (productive time lost)

Often greater than direct costsOften greater than direct costs Greater burden on womenGreater burden on women

Source: Mamdani M & Bangser M. 2004. Poor People’s Experiences of Health Services in Tanzania. A Literature Source: Mamdani M & Bangser M. 2004. Poor People’s Experiences of Health Services in Tanzania. A Literature

Review.Review.

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Ability and Willingness to Pay (WTP) – some estimates

~75% of respondents - “people’s ability to pay for health ~75% of respondents - “people’s ability to pay for health services” has deteriorated during the last five years. (PSSS services” has deteriorated during the last five years. (PSSS 2003)2003)

~40% of respondents - know people who have been ~40% of respondents - know people who have been refused treatment because of inability to pay; over ~25% refused treatment because of inability to pay; over ~25% know “a lot of people”. (PSSS 2003)know “a lot of people”. (PSSS 2003)

Cost of treatment reason given by ~53% of respondents as Cost of treatment reason given by ~53% of respondents as to why they did not seek care when they were last sick… to why they did not seek care when they were last sick… (PSSS)…(PSSS)…even Tshs 500/- fee for consultation is beyond even Tshs 500/- fee for consultation is beyond the meager means of people, especially for women and the meager means of people, especially for women and childrenchildren (TzPPA 2003) (TzPPA 2003)

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Ability ….. (cont)

30-40% of Lindi Rural District are classified as 30-40% of Lindi Rural District are classified as “poor”. Food accounts for 70% of poor “poor”. Food accounts for 70% of poor households’. households’. After minimum non-food After minimum non-food expenditure (school, health, taxes etc.), poor expenditure (school, health, taxes etc.), poor households have only 1% of income flexible households have only 1% of income flexible

= 1,600 Tshs per family per year= 1,600 Tshs per family per year..

Fee range is 200-500 Tshs, but community Fee range is 200-500 Tshs, but community willingness and ability to pay is low; willingness and ability to pay is low; nearly a third nearly a third of familiesof families reported that they had been reported that they had been unable to unable to pay for care in the most recent episodepay for care in the most recent episode..

SC. 2005. The Unbearable Cost of Illness. Tanzania: SC.SC. 2005. The Unbearable Cost of Illness. Tanzania: SC.

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Ability …… (SC study continued)

Ability to pay is seasonal – better at harvest Ability to pay is seasonal – better at harvest time, decreases in dry seasontime, decreases in dry season

For acute illness, 27% resorted to self For acute illness, 27% resorted to self medicationmedication

For For chronicchronic illness, illness, 54% reported taking no 54% reported taking no actionaction mainly because of lack of money. mainly because of lack of money.

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What are the real costs of treatment?Evidence from TzPPA (2003):Evidence from TzPPA (2003):Official fees can be 35% of the total costs [paid at Official fees can be 35% of the total costs [paid at

the facility level]; unofficial fees (hospital the facility level]; unofficial fees (hospital referral, ANC card, syringe, gloves, ‘thank you referral, ANC card, syringe, gloves, ‘thank you for staff’, drugs etc) can constitute 65% of the for staff’, drugs etc) can constitute 65% of the total costs (based on available figures).total costs (based on available figures).

Informal ‘under the table’ payment from patients: Informal ‘under the table’ payment from patients: widespread across many countries and a heavy widespread across many countries and a heavy burden to the poor (CGD 2006)burden to the poor (CGD 2006)

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SC study(cont).…Most significant costs

Acute illnessAcute illness:: Transport, laboratory tests Transport, laboratory tests and drugs. and drugs.

Chronic illnessChronic illness::Traditional healers, Traditional healers, transport and drugs. transport and drugs.

AdmissionAdmission : :Food and accommodationFood and accommodation

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Coping Mechanisms…and further impoverishment Delayed and inadequate treatment, or none at allDelayed and inadequate treatment, or none at all Sale of critical assets (their land, animals, crops, labour…)Sale of critical assets (their land, animals, crops, labour…) Reduced food intakeReduced food intake Take children out of schoolTake children out of school Child LabourChild Labour Borrow moneyBorrow money

In the absence of safety nets….In the absence of safety nets….

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Exemptions / Waivers (e/w)

ExemptionsExemptions: cost-sharing should not apply to : cost-sharing should not apply to children under five, MCH services (including children under five, MCH services (including immunizations), TB, leprosy, paralysis, immunizations), TB, leprosy, paralysis, typhoid, cancer, AIDS and epidemics. typhoid, cancer, AIDS and epidemics.

WaiversWaivers: free services for the poorest of the poor.: free services for the poorest of the poor.

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Are exemptions/waivers effective?“…“…a functional exemption and waiver system is a functional exemption and waiver system is

actually non-existent putting vulnerable and poor actually non-existent putting vulnerable and poor people at risk by practically denying them access people at risk by practically denying them access to public health services.”to public health services.” Laterveer et al 2005Laterveer et al 2005

SC 2005:SC 2005:

Lack of information and understanding about the e/w Lack of information and understanding about the e/w among households and health workers.among households and health workers.

Children under 5Children under 5 – only 20% were exempted for – only 20% were exempted for admissions; 49% for acute cases (at hospital level?)admissions; 49% for acute cases (at hospital level?)

PoorPoor – only 50% were exempted from fees for acute illness – only 50% were exempted from fees for acute illness Better-off benefiting more than the poor on exemptions for Better-off benefiting more than the poor on exemptions for

admissions (23% vs. 12%)admissions (23% vs. 12%)

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Some issues with e/w

What do e/w cover? What do e/w cover?

Who are the very poor? The vulnerable? Who Who are the very poor? The vulnerable? Who decides?decides?

Are people aware of their rights?Are people aware of their rights?

What governance and accountability mechanisms What governance and accountability mechanisms have been put in place?have been put in place?

What incentives do facilities have to grant e/w?What incentives do facilities have to grant e/w?

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Why should the poor benefit less? A “chain of health deprivation”

Perception of health statusPerception of health status & need for care & need for care (norms, beliefs, knowledge)(norms, beliefs, knowledge)

Propensity to seek (formal) care when illPropensity to seek (formal) care when ill (knowledge of danger signs, expectations & (knowledge of danger signs, expectations & experience of health care)experience of health care)

Able to overcome barriers to accessAble to overcome barriers to access (distance, cost (distance, cost (real and indirect), socio-cultural)(real and indirect), socio-cultural)

Actually receive Actually receive quality carequality care Willing & able to Willing & able to comply with treatmentcomply with treatment

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The poor are…

Less likely to perceive illness or “need” in the first Less likely to perceive illness or “need” in the first placeplace

Less likely to seek treatment when illLess likely to seek treatment when ill Less likely to use formal providersLess likely to use formal providers More affected by cost barriersMore affected by cost barriers More affected by distance barriersMore affected by distance barriers Also affected by social barriersAlso affected by social barriers Less likely to obtain quality care even if they Less likely to obtain quality care even if they

attendattend

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Challenges facing the health system

Underskilled & de-motivated health staffUnderskilled & de-motivated health staff Weak management systemsWeak management systems Poor quality of carePoor quality of care Inadequate information to health consumersInadequate information to health consumers Resource constrainedResource constrained Growing burden…..(CDs + NCDs)Growing burden…..(CDs + NCDs) Poor access by the very poor to health care, etcPoor access by the very poor to health care, etc

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HR - many needier and poorer Tanzanians are underserved compared to the better off

Highly uneven geographical HR distribution and Highly uneven geographical HR distribution and gap has been wideninggap has been widening: : In 2007/08: the best served region had twice the In 2007/08: the best served region had twice the

number of health workers per 10,000 persons number of health workers per 10,000 persons than the worst served regionthan the worst served region

Areas chronically under funded and with lowest Areas chronically under funded and with lowest staffing allocations have the highest rates of staffing allocations have the highest rates of povertypoverty Per capita health staffing budget in 2008/9: Per capita health staffing budget in 2008/9:

Tshs 1,400 - Tshs 14,000 across LGAsTshs 1,400 - Tshs 14,000 across LGAsSource: GBS. 2008. Equity and Efficiency in Service Delivery: Human Resources. Background Analytical Note for the Source: GBS. 2008. Equity and Efficiency in Service Delivery: Human Resources. Background Analytical Note for the

Annual Review of GBS 2008, Tanzania.Annual Review of GBS 2008, Tanzania.

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Human Resource…… An absolute shortage of skilled workers Difficulties in attracting and retaining workers to

underseved areas + continued recruitment and transfers to better served districts

High absenteeism Poor productivity of existing staff

2007/08: MoHSW (Tz) recruited 3,645 workers, only 2,533 actually took up positions; 122 health workers were sent to Rukwa but only 31 reported, leaving 8 facilities un-operational due to staff shortages

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High absenteeism, low productivity, leakages ….chronic in developing countriesCGD 2006:CGD 2006: UgandaUganda

only 56% of facility staff existed in district records only 56% of facility staff existed in district records (ghost workers); (ghost workers);

average leakage rate for drugs in public rural facilities average leakage rate for drugs in public rural facilities was some 73%, ranging from 40-94%was some 73%, ranging from 40-94%

Nigeria Nigeria 42% of staff had not been paid their salaries for 6 42% of staff had not been paid their salaries for 6

months in the past year; months in the past year; 25% of health facilities had half the minimum pkg of 25% of health facilities had half the minimum pkg of

equipment; 40% had less than a quarter of what was equipment; 40% had less than a quarter of what was needed.needed.

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LGA: insufficient funding to deliver quality health services…..

DxD : LGA responsible for delivery of quality DxD : LGA responsible for delivery of quality health serviceshealth services

LG Budget: formula based recurrent block grants LG Budget: formula based recurrent block grants ({PE}, OC) + development budget({PE}, OC) + development budget

2008/9: development (28%), OC (14%), PE (58%)2008/9: development (28%), OC (14%), PE (58%) Council Plans (basis of planning - HMIS? delink of Council Plans (basis of planning - HMIS? delink of

planning and budgeting….)planning and budgeting….) Teachers and health workers are the largest items of Teachers and health workers are the largest items of

expenditure in LG budgets: approx 50% of all expenditure in LG budgets: approx 50% of all financial resources used at LG levelfinancial resources used at LG level

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Public Expenditure Tracking….

…………in Ghana leakage was 70% of total transfers; it was 40% in Ghana leakage was 70% of total transfers; it was 40% in Tanzania (results in inadequate funding for non-salary in Tanzania (results in inadequate funding for non-salary spending and patients end up “contributing) (CGD 2006)spending and patients end up “contributing) (CGD 2006)

Role of complexity of parallel financing Role of complexity of parallel financing mechanisms to the district, difficulties in mechanisms to the district, difficulties in accessing resources and strategic accessing resources and strategic planning…….harmonisation & reform systems?planning…….harmonisation & reform systems?

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Health System Accountability in Tanzania

Health Facility Governing Committees (HFGCs) Health Facility Governing Committees (HFGCs) introduced at all levels of the health system as a introduced at all levels of the health system as a mechanism for improving accountability between mechanism for improving accountability between health care providers and communities. health care providers and communities. Responsible for:Responsible for: Community participation in health systemCommunity participation in health system Improving quality of careImproving quality of care Ensuring effective exemptionsEnsuring effective exemptions Mobilising resources from communities (eg Mobilising resources from communities (eg

CHF)CHF)

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Rapid appraisal findings related to‘community voice’ within HFGCs HFGCs largely reflect the interests of providers

rather than communities HFGC needed local government approval and

support to access community members. HFGC agenda had to be fitted into a broader

village meeting agenda. Communities were generally wary of the HFGC

due to a broader distrust of government structures and a distrust of providers which also extended to the HFGC.

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Towards strengthening the system ….(CGD 2006)

Better managementBetter management: adequate incentives for health : adequate incentives for health professionals (supervision, enabling environment, PBF)professionals (supervision, enabling environment, PBF)

Improved logistics and information systemsImproved logistics and information systems: drug : drug procurement reform, insitutional incentives e.g. hire and procurement reform, insitutional incentives e.g. hire and fire staff; HR database - matching staff and wage fire staff; HR database - matching staff and wage payments, eliminate abusespayments, eliminate abuses

Strengthened accountabilityStrengthened accountability: oversight and enforcement, : oversight and enforcement, health provider audits, community oversight, patient health provider audits, community oversight, patient satisfaction surveys, citizens access to information on satisfaction surveys, citizens access to information on resource flows and roles and responsibilities, citizen report resource flows and roles and responsibilities, citizen report cardscards

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Tanzania is committed….

MkukutaMkukuta (the National Strategy for Growth (the National Strategy for Growth and Poverty Reduction) seeks to: and Poverty Reduction) seeks to:

““Improve quality of life and social well-Improve quality of life and social well-being, with particular focus on the poorest being, with particular focus on the poorest and most vulnerable groupsand most vulnerable groups” ” and…“and…“Reduce inequalities across Reduce inequalities across geographic, income, age, gender and other geographic, income, age, gender and other groupsgroups””

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But there are huge challenges…..

Significant gains in child survival risk being undermined Significant gains in child survival risk being undermined by pervasive poverty, especially in rural areas: by pervasive poverty, especially in rural areas: 34% of households living below US$1/day (HBS 2007)34% of households living below US$1/day (HBS 2007) Dependent on aid - about 40% of national budget in the Dependent on aid - about 40% of national budget in the

past few yearspast few years Disparities in child survival persist - between districts and Disparities in child survival persist - between districts and

regions, urban vs rural, and by wealth status. regions, urban vs rural, and by wealth status. Those living in rural areas and those in poverty remain Those living in rural areas and those in poverty remain

disadvantaged both in terms of service uptake and disadvantaged both in terms of service uptake and outcomes.outcomes.

System -cope with continuing high burdens of System -cope with continuing high burdens of communicable diseases and growing NCDscommunicable diseases and growing NCDs

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Key financing issues Commitment to gradually moving away from OOP

payments Effectively identifying and protecting the

vulnerable Potential of scaling up range of CBHIs…common

bond concept? Promote cross-subsidies in overall health system:

Improved tax funding levels Reduce fragmentation of risk pools Extension to non-formal sector from outset

Equitable allocation of tax (and donor) funds according to need