MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES STRENGTHENING HEALTH SYSTEM RESEARCH CAPACITY FOR ENHANCING INNOVATIONS AND SUSTAINABLE SOCIO-ECONOMIC DEVELOPMENT NAME AND CONTACT INFORMATION OF COOPERATING PARTNERS: School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences Contact person: Prof. A. D. Kiwara Department of Development Studies Email: [email protected] Department of Public Health and Clinical medicine Umeå University SWEDEN Contact person: Prof. Anna-Karin Hurtig Email: [email protected]. Coordinator/Department Tanzania Institution Swedish Institution School of Public Health and Social Sciences, Department of Public Health and Clinical medicine Muhimbili University of Health and Allied Sciences Umeå University (MUHAS) SWEDEN PI/Main coordinator: Prof. A. D. Kiwara PI/Coordinator: Prof. Anna-Karin Hurtig E-mail: : [email protected] E-mail: [email protected]. Deputy PI/Coordinator: Dr. Gasto Frumence E-mail: [email protected] APRIL 2014 Summary People centered health systems are important in ensuring universal health coverage - whereby all people are enabled to have access to the health services they need without risk of financial ruin or impoverishment (WHO, 2013). In essence, strong health systems should address two aspects of universal health coverage, namely: the provision of, and access to, high-quality health services; and financial risk protection for people who need to use these services. Nevertheless, the health systems of low income countries such as Tanzania are currently in a crisis arising out of multiple factors connected with the overall economic challenges facing these countries. The broad manifestation of the crisis is seen in the poor performance of the health care systems. Improving the performance of health systems is a key factor behind the improvement of health services delivery and overall improvement in the health and well being of the people and so alleviation of poverty. However, improving the health systems performance requires interventions targeting the various aspects of the health system that are impinging on its performance. These aspects include but not limited to the three broad areas of human resources, financing, organization and governance of the health care delivery system. In response, a training programme is being proposed which will offer PhD, Post-doc, and Masters Opportunities. The Masters programme is a new one: MSc – Project Management, Monitoring and Evaluation in Health Care. Objectives of the Research sub-program: The overall objective is to investigate and produce evidence (knowledge and insights) on the factors that influence the health system functioning with the aim of improving its performance and ultimately the health status of the population in Tanzania. Whereas the main outcome of the proposed project will be to train high level human resources it is also envisaged that through the training, there will be strengthening of the health system capacity towards achieving universal health coverage. Specifically the proposed project intend to understand the role of enhanced Health System governance and accountability on strengthening the health system towards achieving universal health coverage; generate information on Human resources management, system strengthening and service provision and to enhance health care financing options and meeting the challenges of protecting the vulnerable. Popular science description Effective health systems are essential for delivering good care to the population. However, most health systems in low and middle income countries are weak and fragmented which make it difficult to reach the goal for a health system to improve health, social and financial protection, and responsiveness to the expectations of the population. The attention for health systems strengthening has therefore emerged during the last years. To build capacity in health systems research is therefore high on the global health agenda. 2 The ongoing collaboration between Muhimbili University of Health and Allied Sciences (MUHAS) and Department of Public Health and Clinical medicine, Umeå University, Sweden aims to contribute to fill the gap of researchers trained in health systems research in Tanzania. The collaboration will particularly focus on the three broad areas of human resources, financing, organization and governance. The collaboration has in its first phase(2009-2015) laid the foundation for the upcoming phase through training of two PhD students and research projects carried out in the Dodoma region by post docs and senior researchers with a focus on human resources, decentralization and governance. The upcoming phase will expand the training component and include three PhD students, three post docs and four Master students working together with senior researchers in Tanzania and Sweden. The health system cluster is believed to be an asset also for other research clusters at MUHAS and collaborations between clusters will be encouraged during the project period. 1. Introduction People centered health systems are important in ensuring universal health coverage - whereby all people are enabled to have access to the health services they need without risk of financial ruin or impoverishment (WHO, 2013). In essence, strong health systems should addresses two aspects of universal health coverage, namely: the provision of, and access to, high-quality health services; and financial risk protection for people who need to use these services. Nevertheless, the health systems of low income countries such as Tanzania are currently in a crisis arising out of multiple factors connected with the overall economic crises facing these countries. The broad manifestation of the crisis is seen in the poor performance of these systems. Improving the performance of health systems is a key factor behind the improvement of health services delivery and overall improvement in the health and well being of the people and so alleviation of poverty. However, improving the health systems performance requires interventions targeting the various aspects of the health system that are impinging on its performance. These aspects include but not limited to the three broad areas of human resources, financing, organization and governance of the health care delivery system (see conceptual framework Fig 1). The proposed research sub-program therefore is essentially a multi disciplinary research aimed at investigating how the various elements of the Tanzania health system impact on the overall functioning of the system. The overall objective is to produce knowledge and insights through research that will help policy making and improvement in the performance of the system to produce optimal health results to the population fuelling their capacity to improve quality of health services. 3 4 Objective of the Research Program: The overall objective is to improve the capability of the health system in addressing problems related to governance, human resource management and health care financing in contributing to the efforts of alleviating poverty in Tanzania by 2020. Whereas the main outcome of the proposed project will be to train high level human resources at the Masters and PhD levels, it is also envisaged that through the training, there will be strengthening of the research capacity both at the Institutional (MUHAS) and national (health system) level towards achieving innovation and sustainable socio-economic development. In that course the following are the specific objectives that shall define the themes to be tackled. Specific objectives: The following presents the thematic areas defined by the building blocks within which are sub-specific objectives reflecting the areas of research interest to guide the envisaged PhD and master‘s candidates as follows: 1. Understand the role of enhanced Health System governance and accountability on strengthening the health system towards achieving universal health coverage. Within this objective the sub-objectives will be to determine the following:- 1.1 To increase number of trained professionals who apply their new skills and knowledge in Project management, monitoring and evaluation in health care 1.2 To increase number of trained professionals who apply their knowledge and skills in strengthening the health system by developing and utilizing specific courses‘ curricula in health system. 1.3 To develop capacity to improve understanding of the role of decentralisation by devolution in creating an accountable health system 1.4 To improve understanding of what works and what doesn‘t with respect to the role of Public Private Partnership in enhancing equity, access and quality of health service 1.5 To develop capacity to enhance understanding the role of governance in prevention and combating corruption in health service delivery 1.6 To develop capacity for supporting Council Health Management Teams to and others district governance structures to acquire knowledge and skills in health management 5 1.7 To promote community participation through enhanced social capital with the ultimate goal of improving quality of health care, equity and health access for all. 2. Generate information on Human resources management and system strengthening and service provision. Specifically the sub-specific objectives will be to:- 2.1 To develop capacity to enhance understanding of the dynamics of training and managing critical health care cadres in a reformed, market economy led and private public partnership driven health care system. 2.2 To raise capacity to understand the deployment process, retention mechanisms and attrition drivers in place. 2.3 To increase capacity to use and manage human resource management information systems in place and identify possible aspects for improvement 2.4 To develop capacity to master appropriate mix of HRH planning and forecasting in the regions and the health care system at large 2.5 To determine the implications of current performance appraisal systems for frontline health care workers and CHW, their interactions and productivity. 2.6 To determine the effects and implications for the implementation challenges of new Community Based Health Workers (CBHC) policy guidelines. 3. To enhance health care financing options and meeting the challenges of utilizations and protection of the vulnerable groups with an aim of improving their health status. Sub-specific objectives under this theme shall be to: 3.1 To explore the role of client‘s knowledge and competence on rights to health information and their relationship to joining risk sharing schemes and accessibility of health services. 3.2 To analyse accessibility to essential medicine and their relationship to joining risk sharing schemes 3.3 To explore ways and means of sustaining Community Health Fund (CHF) within the community 3.4 To Identify and respond to gaps in health information literacy in relationship to utilization of health services among vulnerable groups. 3.5 To explore and promote ways of community solidarity in financing health and protection of vulnerable groups. 6 2. Background 2.1. The context of the programme in relation to the university concept paper. The importance of health systems in ensuring improved health status of the people cannot be over emphasized. The health systems of low income countries such as Tanzania are currently in a crisis arising out of multiple factors connected with the overall economic crises facing these countries. The broad manifestation of the crisis is seen in the poor performance of these systems, due to inadequate human resources, poor supply of health commodities, limited financing, and inefficient organization and governance. In response to these challenges, the proposed research and training programme which falls under objective number 5 of the university concept note is aimed at strengthening the capacity of young and prospective academicians and researchers for health system research. The programme addresses key health system blocks of health system governance and accountability, human resources for health and health care financing and access to essential medicines. Both partner institutions MUHAS Umeå University have common interests in terms of capacity building through training and research in the identified areas of health system strengthening. The collaboration started in the previous period (2009-2015) supported by Sida. Both partners see the need to continue with the process of training researchers in health systems and policy research. 2.2. The scientific issues and basis for the research training programme. The proposed health system strengthening programme will cover three major themes, all of which address health systems blocks. These themes will constitute sub-programs of the project as described below:- 2.2.1. Health System governance and accountability According Tanzania´s National Strategy for Growth and Reduction of Poverty as well as Vision 2025 good governance and accountability is cited as an important principle for ensuring service providers deliver effective, and people centered services (NSGRP 2010, URT 2000). Currently health system governance is exercised through the policy of decentralization by Devolution (D by D), which has moved many planning and budgetary responsibilities for service delivery from the central government to the district level. This is seen as a strategy of empowering grassroots communities to manage their own affairs and at the same time ensure accountability of public servants. However, recent 7 studies conducted in the first phase of health systems strengthening under Sida supported projects (Frumence et al., 2013, 2014A, 2014B; Tumaini et al., 2013); a number of considerable challenges facing the implementation of decentralized health care delivery system at the district and lower level were identified. Many of the bottlenecks identified are related to the key issues of poor governance, inadequate human resources for health and inadequate financing and access to essential medicines. These issues are a subject of the proposed research and training program so as to explore them deeply. Furthermore, other studies conducted in Tanzania have also pointed out that corruption is a major hindrance in the delivery of quality health services and ensuring equity in accessing health services by all citizens particularly the poor people (SIKIKA, 2010). Despite the existence of rampant corruption in the health sector, yet, little has been systematically documented on the role of decentralized governance health structures in controlling and preventing corruption in the health sector. Another component of the suggested program of collaboration concerns the role of Public Private Partnership (PPP) in improving access to health services particularly to the most vulnerable populations such as women and children. In the late 2000s the government of Tanzania introduced the policy of public private partnership (PPP) aiming at involving private sector in the delivery of social services including health services particularly to the most vulnerable populations such as women and children under five as one of the ways of improving access and quality of health services in the country. However, since the introduction of PPP little has been documented on the successes and failures of the newly introduced partnership and the role of decentralized governance structures in the health systems in fostering PPP in the health sector. The proposed training programme is an attempt to fill that gap. 2.2.2. Human resources for Health The second theme under the health system project is about human resources. Tanzania has a serious and increasing shortage of skilled health workers at all levels, which is compromising the ability of the health care system to deliver quality health services to its people. The shortage is more severe in rural and hardship areas and among mid- level health workers such as nurses, clinicians, midwives, pharmaceutical and laboratory technicians, health officers and administrators. According to the Human Resources for Health Strategic Plan (2008 - 2013), the health staffing shortage across all cadres stands at 65% of the actual need within the public health system, and 86 percent within the private health system. The Human Resources for Health (HRH) 8 deficit becomes even significantly larger when the requirements of the Primary Health Care Services Development Programme (MOHSW, 2007) are factored in; this program, with the acronym in Kiswahili MMAM, requires the establishment and staffing of an additional 3,108 dispensaries, 2,074 Health Centers and 8 District Hospitals by 2017. Also, the deficit is further exacerbated by a rapidly expanding population, as well as an increasing burden of disease due to HIV/AIDS, which both increases the demand on the health system and increases health worker attrition rates. Tanzania is losing an estimated 300 health workers per year through attrition and ‗brain drain‘ (MoHSW, 2008). Problems in recruitment can be demonstrated by the fact that between 1995 and 2005, during which there was freeze of employment, health training institutions produced 23,474 staff of which only 16% were employed in the public sector (MoHSW, 2008). The Government lifted the employment freeze and allowed Councils to recruit health workers directly. Most of the councils, particularly the rural ones, failed to acquire the required number of skilled staff. The MOHSW was called to rescue the situation. MOHSW had been posting staff to the Districts based on the hiring permit received from POPSM for the last three years from 2007/2008. Human Resources for Health production has increased impressively in the country in the recent past. Altogether currently there are 153 Human Resources for Health training institutions in Tanzania. There are ten University level institutions training Doctors of Medicine, Pharmacists, Dental Surgeons and Degree level Nurses. Twenty-four institutions train Clinical Officers and 68 institutions train Nurses and Midwives. For the Doctors of Medicine a recently concluded Sida funded research established that production has increased sixteen times. The puzzle is that shortages of Doctors have persevered. 53 districts do not have a medical officer and 89 districts do not have a Dental Surgeon. A recent health worker tracking study (Sirili et al., 2014) indicates that a substantial number is not reporting where they are posted despite availability of employment permits. For those who were posted to different work stations 13% never reported while another 37% left their work stations almost immediately after reporting. Given these challenges Community Health Workers are assuming a more important role in health care delivery and preventive services. Recent studies in Tanzania, India and elsewhere confirm this (Ministry of Health and Social Welfare, 2014). An outstanding challenge, however, is sustainability given the limited resources. Arguments revolve around monetary and non-monetary incentives, training and technical support from frontline health workers. A deeper understanding of dynamics surrounding this cadre and enhancing its productivity is now more than before needed. Despite the increased enrolment of students at various levels and graduation, the HRH crisis has continued to challenge the health care system in Tanzania. It is being proposed by this capacity building sub program that search for a deeper understanding of this problem should go beyond numbers only and address other aspects related to 9 Human Resources for Health needs including forecasting and planning, general management aspects, the deployment process, retention and attrition drivers. 2.2.3. Health care financing and access to health information Universal coverage in accessing health care is a priority in developing world. Accessibility to acceptable quantity of health services and quality health care remain a challenge for about 1.3 billion people worldwide; being more exacerbated in developing countries including Tanzania (REPOA, 2006). The most commonly used dimensions to explain accessibility are physical accessibility to health facilities, availability of diagnostic equipment in health facilities, availability of efficacious, safe and affordable medicines, are crucial aspects in improving access to health care (Thiede et al, 2007). Specifically, a number of factors have been associated with poor accessibility to health care in Tanzania include: unaffordable transport systems; poor quality of care; poor governance and accountability mechanisms; and poorly implemented exemption and waiver schemes meant to protect the most vulnerable and poor people (Mujinja et al 2013, Kida 2009). Other pressing aspects in this area have been the way in which alternative financial mechanisms can be molded to protect those who are in need from catastrophic health expenditure. Accessibility to health care has different multi-sectoral dimensions. Rarely the literature would look at the right to information of the services that are provided by health facilities as an important factor in facilitating accessibility. Accessibility is influenced by the availability of information on what type of health services and health workers are available in health facilities. All dimensions of accessibility and utilization of health services (affordability, availability, appropriateness, quantity and quality, acceptability), are in one way or another limited by the right to information by different groups in rural areas. This has consequently resulted into creation of more inequity in health care access (Mujinja and Kida, 2014). Health information is a ‗public good‘, and it has been found to increase health care utilization and improve health status where the population has been more elite on health issues. 10