Stakeholders in Tanzania identify areas for BACKUP Health technical support
Samuel MuniuArticle Type:
Article Number: 6
The Global Fund and Gavi have separate and parallel dialogue structures
ABSTRACT German International Development Cooperation commissioned a needs assessment in Tanzania between March and July 2021 to identify BACKUP Health technical support areas to strengthen the country’s health systems. On 16 September 2021, BACKUP Health, in collaboration with the Tanzania National Coordinating Mechanism, organized a stakeholder workshop to validate the key results and recommendations of the needs assessment. The workshop participants, some of which attended face-to-face while others virtually, were government officials, representatives of bilateral and multilateral organizations, and civil society.
Tanzania is among the six countries that receive support in the area of health systems strengthening through the BACKUP Health initiative. BACKUP Health is commissioned by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ). Within the framework of its co-financing agreement with the UK Foreign, Commonwealth & Development Office (FCDO), BACKUP supports five additional countries: the Democratic Republic of Congo (DRC), Mozambique, Nigeria, Uganda, and Zimbabwe. In our earlier article in GFO issue 404, we provided details of BACKUP Health’s support to countries to efficiently use resources provided by global financing mechanisms (Stakeholders in Uganda identify areas for BACKUP Health technical support).
GIZ commissioned a needs assessment in Tanzania between March and July 2021 to identify areas that BACKUP Health could support to strengthen health systems and leverage support from Global Financing mechanisms. In collaboration with the Tanzania National Coordinating Mechanism (TNCM), BACKUP Health held a stakeholder workshop on 16 September 2021 to share and validate the key results and recommendations of the needs assessment. The workshop participants, attending both physically and virtually, were government officials, representatives of bilateral and multilateral organizations, and civil society.
Aidspan attended the stakeholder workshop as an observer, and this article highlights the key issues that were discussed.
Findings of the needs assessment in Tanzania
The needs assessment team obtained information through a mixed methods methodology. Its members reviewed relevant documents, including health sector plans, national disease plans for AIDS, malaria, tuberculosis (TB), and leprosy, funding requests to global financing mechanisms, and the Comprehensive Multi-Year Plan for the Immunization and Vaccine Development program. The team followed a participatory approach and also held roundtable discussions with key stakeholders, including government officials, civil society, and bilateral and multilateral organizations. In addition, it reviewed the outputs, targets, indicators, and outcomes of the BACKUP health program.
Global financing mechanism-supported programs are inadequately aligned with national priorities
Global financing mechanisms play a critical role in bridging a country’s financial gap to successfully implement its key national priorities, spelled out in the national strategies for specific programs. However, the needs assessment found that national strategies for AIDS, TB, and malaria were not fully aligned with Tanzania’s fourth health sector strategic plan for 2015-2020 (HSSP IV). The strategies were not in line with timeframe, goals, objectives, implementation arrangements, and governance. Fully aligning all strategies and integrating them into existing systems is essential for global financing mechanisms to be able to achieve a more meaningful impact in Tanzania. The team conducting the needs assessment noted that aspirations to align vertical programs are one of the recommendations in the fifth Health Sector Strategic Plan 2021-2026 (HSSP V).
The findings noted a need for technical assistance to support the review and development of disease-specific strategies to align with HSSP V. Also, there is a need to provide both technical and financial assistance to review the national guidelines for key and vulnerable populations (KVPs) to ensure that these too are aligned with HSSP V.
Separate and parallel national dialogue structures
Sector-wide approaches (SWAPs), an international development framework that brings together governments, donors, and other stakeholders within a sector, provides a framework within which all resources in a sector can be managed in an integrated and coherent manner (also known as basket funding because all resources are pooled under one umbrella). It thus provides a platform for a national dialogue on a sector policy issue. However, the needs assessment revealed that both the Global Fund and Gavi, the Vaccine Alliance, have separate national dialogue structures parallel to the national health SWAP structure in Tanzania. Merging and integrating these structures would allow the establishment of one Technical Working Group (TWG), alignment of annual field visits, and conducting joint annual health sector review meetings.
Inadequate participation of civil society in the Global Fund and Gavi dialogues
The participation of all relevant stakeholders in national discussions is essential for a program to meet the diverse need of its stakeholders and, if built on consensus and tailored to their needs, stands a greater likelihood of success. However, the needs assessment found that civil societies were inadequately involved in the Global Fund and Gavi national dialogues. Gavi’s national dialogue, the Inter-Agency Coordination Committee (ICC), is limited to immunization partners. Civil society constituencies participate in the Global Fund national dialogue through meetings organized by the TNCM for funding request development, as well as their presence on the TNCM as elected representatives of civil society. However, they do not hold many seats on the TNCM, and their capacity is weak which hampers their effective participation in the national dialogue and the development of funding requests.
Clearly, there is a need to include civil society immunization stakeholders in the ICC. Moreover, technical assistance is needed to enhance KVPs’ and civil society’s capacity to meaningfully contribute to the TNCM processes.
Global financing mechanisms lack a holistic health system strengthening approach
The existence of an integrated, holistic, strengthened, and sustainable health system is essential to improving any country’s health and individual well-being. However, the needs assessment revealed that the global health mechanisms active in Tanzania have vertical or standalone programs that offer piecemeal approaches that are inadequately linked to health system strengthening (HSS) targets. Integrated or well-linked programs are more likely to have better health outcomes through a holistic approach that addresses several health issues simultaneously, to the extent possible, and supports referrals between services, for example. Nevertheless, there are several achievements that both the Global Fund and Gavi can leverage to improve and sustain HSS in Tanzania, including:
- The District Health Information Software – Version 2 (DHIS2) has integrated the information systems for HIV, TB, malaria, and immunization.
- The Directorate of Health Quality Assurance’s (DHQA) Star Rating Assessment, which assesses service delivery of health care facilities and rates them on a scale of one to five stars, and the Office of Internal Auditor General’s independent verification of health sector results have led to improvements in data quality and an improved focus on results.
- There are information systems available at the local government authority level, such as Facility Financing Accounting and Reporting Systems (FFARs) and the Integrated Monitoring and Evaluation System (iMEAS)
However, these systems are under-utilized due to their users’ lack of skills and capacity. Consequently, the team conducting the needs assessment recommended the need for technical assistance to build the capacity of health information system users to improve data efficiency. Also, there is a need to expand the independent verification of health results to include indicators for global funding mechanism-funded programs.
Need to manage COVID-19-related risks
A coordinated response to the COVID-19 pandemic is the basis of an effective response to prevent the spread of coronavirus. In Tanzania, the COVID-19 Response Unit at the Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC)coordinates support from development partners and leads the development and implementation of the National Preparedness and Response Plans. However, the needs assessment found that donor-funded COVID-19 response programs are implemented vertically rather than adopting system-wide approaches such as Direct Health Facility Financing (DGFF) and the SWAP’s Health Basket Fund (HBF). In addition, the needs assessment identified the importance of supporting the dissemination of previously developed guidelines and tools to health facilities (HFs). There is a need to support most community-based organizations and HFs with personal protective equipment (PPE). Also, technical assistance is required for the MOHCDGEC’s Health Promotion Section to develop guidelines to integrate Social and Behavior Change Communication (SBCC) in the COVID-19 response.
Ongoing reforms to healthcare financing needed to support universal health coverage
The Government of Tanzania has introduced pre-payment schemes for health insurance to achieve universal health coverage (UHC). At the time of conducting the needs assessment, the draft Universal Health Insurance Act was being reviewed by the Cabinet of the United Republic of Tanzania. Also, the Cabinet was examining a mechanism for identifying the poor and financing their health insurance needs. The country is still looking into the actual costs of health service delivery to inform the revision of cost-sharing guidelines. Also, it is still introducing strategic purchasing of health services that aim to increase health system performance through the effective allocation of financial resources to providers to promote public health goods.
However, other Ministries, such as the Ministry of Finance and Planning, are not necessarily familiar with the concept of UHC and the government’s role in providing funds for UHC. According to the team conducting the needs assessment, Providing for Health (P4H), a network of a broad mix of international partners working on health financing for UHC, could support the coordination of the health financing reforms at both national and sub-national levels, including revitalizing the focus on HIV prevention. Specifically, P4H could provide analytical, technical, and advocacy support for UHC. Unfortunately, P4H is underutilized by both the government and the global financing mechanisms, even though the Global Fund itself is a P4H member.
The need for technical assistance to Tanzania remains evident, in particular to:
- Develop long-term health infrastructure mapping and investment plans in line with population and economic growth;
- Conduct studies on allocative efficiency that requires health providers to choose a combination of inputs in accurate proportions relative to their prices, thereby choosing outputs with minimal average costs of health resources in the health sector
- Conduct studies to profile household income in relation to universal health insurance; and
- Determine the actual cost of healthcare services at the various levels to inform cost-sharing and individual contributions to health insurance schemes.