A PERFORMANCE AUDIT REPORT ON THE MANAGEMENT OF PRIMARY HEALTH CARE: A CASE STUDY OF HEALTH CENTERS

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1 THE UNITED REPUBLIC OF TANZANIA NATIONAL AUDIT OFFICE (NAO) A PERFORMANCE AUDIT REPORT ON THE MANAGEMENT OF PRIMARY HEALTH CARE: A CASE STUDY OF HEALTH CENTERS A REPORT OF THE CONTROLLER AND AUDITOR GENERAL OF THE UNITED REPUBLIC OF TANZANIA

2 2008 Office of the Controer and Auditor Genera of Tanzania No part of this materia may be reproduced without the express permission of the Controer and Auditor Genera of Tanzania. The Controer and Auditor Genera, Nationa Audit Office, Samora Avenue/Ohio Street, P. O. Box 9080, Te: +255 (022) /8, Fax: +255 (022) / , E-mai: Dar es saaam, Tanzania.

3 Tabe of Contents Preface... v Abbreviations and acronyms...vi Executive summary... 1 CHAPTER ONE INTRODUCTION 1.1 Background Purpose of the audit and the audit questions Audit design Structure of the Audit... 9 CHAPTER TWO DESCRIPTION OF THE AUDIT AREA 2.1 The heath care poicy Roes and responsibiities Funding CHAPTER THREE HEALTH CENTERS PERFORMANCE 3.1 Funding and workoad Workoad and time for waiting and processing Other findings CHAPTER FOUR MANAGEMENT OF HEALTH CENTERS 4.1 Performance management among the Councis Monitoring by the Regiona authorities Linkage between management activities and the HCs performance CHAPTER FIVE SUPPORT FROM ACTORS AT NATIONAL LEVEL 5.1 Nationa support to regiona and counci eve Actions to foow up PHC system CHAPTER SIX CONCLUSION 6.1 Correation between resource aocation and performance Heath management information system Linkage between performance and poicy making Information to the nationa eve A performance Audit Report on the Management of Primary Heath Care Performances iii

4 CHAPTER SEVEN RECOMMENDATIONS 7.1 To the Municipa/district Counci To the Regiona Secretariat To the Prime Minister s Office Regiona Administration and Loca Government To the Ministry of Heath and Socia Wefare REFERENCES APPENDICES Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Appendix 10 Appendix 11 Appendix 12 Appendix 13 Appendix 14 Appendix 15 Appendix 16 Appendix 17 Appendix 18 Appendix 19 Appendix 20 Appendix 21 Appendix 22 Appendix 23 Average number of visitors per day compared with drugs aocation per quarter in shiings List of HCs with their respective workoad and WPT List of HCs with their respective casses of performance scores A comparison of performance (Waiting and Processing time & average number of visitors per day) with resource aocation Heath center average number of visitors per day compared with the staff avaiabe Supervision carried out by CHMT to their respective heath centers A ist of activities budgeted by Councis for rura heath centers and reported as fuy impemented whie HC have not been benefited Supervision visit at Councis conducted by the RHMTs A comparison of performance (waiting time and workoad) with outstanding baance in MSD for year ended 31 st December Numbers of days Essentia drugs were missing in the heath center against funds baance at the MSD for the year 2007 Poverty (Percentage of Peope iving beow basic poverty ine in the counci) Criteria used to assess counci progress Financia and technica reports List of Regions, Councis and Heath Centers visited during the audit assignment. List of Councis with their respective number of HCs and Medica Staff. Methods used to coect data of waiting and processing time (WPT) and workoad from HCs visited. Number of supervision visits conducted by RHMTs Anaysis of findings of CHMTs supervision reports reviewed. Anaysis of recommendations of CHMTs supervision reports reviewed Individuas/management interviewed Workoad and waiting and processing time Concept A comparisons of externa factors between heath centers Workshop participants List of Charts, Figures, Photos and Tabes iv A performance Audit Report on the Management of Primary Heath Care Performances

5 PREFACE Pursuant to section 28 of the Pubic Audit Act No. 11 of 2008, the Controer and Auditor Genera has been mandated to carry-out Vaue-for-Money (VFM) or Performance Audit in the Ministries, Departments, and Agencies (MDAs), Regions, Loca Authorities and Pubic Authorities and other Bodies. The purpose is to estabish the economy, efficiency and effectiveness of any expenditure or use of resources in the respective audited entity. I have the honor to submit to the Minister of Heath and Socia Wefare for presentation to the Pariament of the United Repubic of Tanzania my performance audit report on the management of Primary Heath Care Services to the citizens of Tanzania Mainand with particuar reference to the management of Heath Centers performance. The report comprises of concusions and recommendations to the Ministry of Heath and Socia Wefare, Prime Ministers Office Regiona Administration and Loca Government, Regiona Administrative Secretariats and Councis. The mentioned auditees have been given the opportunity to comment on the fina draft report before it wi be submitted to the responsibe minister. It is a common interest of the auditees and the CAG that the findings of the PHC audit are factuay correct and presented in a fair way in the fina pubic version of the report. The authorities have been most hepfu in providing vita information, statistics and comments. The audit aims at improving the management of Primary Heath Care services to citizens of the United Repubic of Tanzania. My office intends to carry out a foow-up at an appropriate time regarding actions taken by the auditees in reation to the recommendations of this report. This report has been prepared by Wendy Massoy, Godfrey B. Ngowi and Levina R. Kishimba under the supervision of Gregory G. Teu. I woud ike to thank my staff and aso the auditees for their support and continued finaising cooperation in this report. Ludovick S.L. Utouh Controer and Auditor Genera Dar es Saaam, January 2009 A performance Audit Report on the Management of Primary Heath Care Performances v

6 Abbreviations and Definition of Terms BFC Basket Fund Committee BoD Burden of Disease CAG Controer and Auditor Genera CD Counci Director CHF Community Heath Fund CHMT Counci Heath Management Team CHSBs Counci Heath Service Boards CCHPG Comprehensive Counci Heath Panning Guideine Counci Municipa, City and District Counci DMO District Medica Officer HC Heath Center HFC Heath Faciity Committee HMIS Heath Management Information System HSPS Heath Sector Programme Support IKAMA Standard staffing eve LGA Loca Government Authorities MMO Municipa Medica Officer MoHSW Ministry of Heath and Socia Wefare MSD Medica Stores Department NEHP Nationa Essentia Heath Package NHIF Nationa Heath Insurance Fund OPD Out patients Department PAA Pubic Audit Act PER Pubic expenditure Review PHC Primary Heath Care PMORALG Prime Minister s Office Regiona Administration and Loca Government RAS Regiona Administrative Secretary RHMT Regiona Heath Management Team RS Regiona Secretariat RS/RHMT Regiona Secretariat /Regiona Heath Management Team RMO Regiona Medica Officer SWAP Sector Wide Approach WHO Word Heath Organisation vi A performance Audit Report on the Management of Primary Heath Care Performances

7 WPT EPI FP HIV DC MC CC CCHP Waiting and Processing Time Expanded Program of Immunisation Famiy Panning Human Immuno-deficiency Virus District Counci Municipa Counci City Counci Comprehensive Counci Heath Pan A performance Audit Report on the Management of Primary Heath Care Performances vii

8 Map of Tanzania viii A performance Audit Report on the Management of Primary Heath Care Performances

9 Executive Summary The Primary Heath Care (PHC) is regarded as the cornerstone of the country s Nationa Heath Poicy. PHC is often the first and in many cases the ony pace of contact regarding prevention and treatment in the community. The Heath Centers (HCs) are managed by Loca Government Authorities (LGAs). The Regiona secretariat is the inkage between the poicy makers and the operating eves. They are responsibe for interpreting Government poicies and decisions and safeguarding that the avaiabe resources in this sector are being effectivey distributed and efficienty utiized. Beyond poicy and reguation, the Centra Government s authorities are aso responsibe for the way the PHC system is set up and works. However indications suggest that there are probems in the performance of heath centers. The purpose of this audit was to review whether the HCs are managed efficienty and whether their performance is appropriatey considered in aocating the avaiabe resources. The aim was aso to study if adequate actions are taken to improve the situations. The audit has focused on HCs owned and managed by the Government of Tanzania Mainand. The audit focuses on performance of HCs managed by Loca Government Authorities which are responsibe for a matters pertaining to PHC services as mandated by the Loca Government District Authorities Act No. 7 of 1982 and the Loca Government Urban Authorities Act No. 8 of 1982 as amended the Loca Government Urban Authorities Act No. 6 of Seven regions of various sizes and popuation and with reasonabe accessibiity were chosen. The aim was to incude regions with different conditions. The regions seected were Dodoma, Iringa, Morogoro, Lindi, Coast, Tanga and Mtwara. In short, the seection covers one third of the regions in Tanzania mainand. According to experts, this ought to be enough for the audit. A these regions were visited by the audit team. 20 councis out of the Tanzania s mainand 133 Councis were seected. Councis were chosen to represent various externa conditions, ike geographica, statuary, economic and popuation size. The audit team consisted of three performance auditors. Data were coected through interviewing concerned actors, reviewing documents and direct observation for measuring waiting processing time and daiy workoad. A performance Audit Report on the Management of Primary Heath Care Performances 1

10 Major findings, concusions and Recommendations Audit Findings The major findings of the audit are as foows:- We noted that, the HCs are not efficienty managed and are funded without proper consideration of service demands and performance The Ministry of Heath and Socia Wefare (MoHSW) has set up standards for the staffing of each HC. Considerations of performance, ike workoad and customers/ cients waiting- processing time, are not specificay stated in Government documents addressing the Councis aocation of resources to the HCs. In reaity, the Councis do not fuy guarantee that avaiabe resources are directed and distributed effectivey and thereafter utiized efficienty. For heath care services, funds for HCs are aocated from the Nationa to Counci eve mosty based on demographic criteria. The Councis then may reaocate these resources between their HCs. But this is rarey done. The Counci distribute funds to the HCs for running expenses and medica suppies without proper or specific consideration on service demand and performance. We noted that, few actions have been taken to improve the efficiency and shorten the customers waiting and processing time in the HCs. Many HCs can not say how much the counci is contributing to the heath care because they are not aware of their budget since they get no feedback from the Councis on the approva of their budgets. Furthermore HCs ack a comprehensive system for monitoring of their own spending. In addition, the current system of supervision has not been abe to detect the HCs that have probems with their performance and suggest remedia action. Aso, the conducted supervision by the Counci Heath Management Team (CHMT) and Regiona Heath Management Team (RHMT) has not provided the HCs with adequate support to mitigate those probems. Moreover, it is not possibe to confirm any certain correation between the HCs performance and the conducted supervision. In spite of certain differences in performance and great potentias for improvements, few actions have been taken by the Government Even though the workoad of HCs in many cases is not that high and the waiting time is ikewise sedom extremey ong variations in the HCs performance do exist. For exampe HCs with the same workoad show extended variations in waiting time. HCs with ower workoad may even have onger waiting time than HCs with higher workoad. The opposite aso occurs. These differences in performance seem to be expained mainy by interna factors within the HCs infuence. 2 A performance Audit Report on the Management of Primary Heath Care Performances

11 The reationship between performance and funding for operating cost at the HCs is weak. Drugs are funded without coser examination of needs. Neither does the number of visitors (users of the HCs services) correspond with aocated staff. The existing system for reguar monitoring does not provide the MoHSW and PMORALG with an adequate overview of up dated and comprehensive information about the probems with performance of the HCs. On the other hand, this kind of quaified information has not been requested by the MoHSW. In addition, few evauations regarding the ink between performance and aocation of resources have been initiated and conducted by the ministry and few actions have been taken by the government authorities to improve this situation. Recommendations In order for key actors at District, Regiona and Nationa Leve to further address probems of efficiency and effectiveness in PHC, we recommend the foowing for improved conditions for the heath center:. The MoHSW and PMORALG shoud improve the evauation of the HCs at nationa as we as regiona and counci eve. It is aso of importance with a carification for the Councis that it is of vaue for the management of the HCs to consider performance issues, ike workoad and waiting - processing time. The Regiona secretariat shoud put more emphasis on performance issues in their monitoring and evauation of PHC at counci eve. This incudes aso examinations on how the Councis manage to safeguard effective aocation and efficient utiization of avaiabe resources for their PHC services. For the Councis a main issue is an active promotion of efficient spending of avaiabe resources for PHC services. This incudes a cear budget for the HCs and a reguar monitoring of their spending and performance. Most important is aso, to make reaocation of resources among the HCs based on their performance. SCRUTINY OF FACTS The Prime Minister s Office Regiona Administration and Loca Government (PMORALG) and the Ministry of Heath and Socia Wefare (MoHSW) which are directy concerned with this report have been given the opportunity to correct factua errors in the draft report. We wish to put on record that the meetings with each Ministry under the management of primary Heath Care performances have been constructive. A performance Audit Report on the Management of Primary Heath Care Performances 3

12 Chapter One Introduction 1.1 Background Primary Heath Care (PHC) is regarded as a crucia eement of a nationa heath care deivery system and is beieved to stimuate the efforts reaching the Miennium Deveopment Goas and efficient impementation of Nationa Strategies for Growth and Poverty reduction. The major aim of PHC is to improve the citizens heath and we being in Tanzania. Through the Ministry of Heath and Socia Wefare (MoHSW) the Government recognizes the PHC as the cornerstone of Nationa Heath Poicy. PHC is the first pace of contact regarding the issue of prevention and treatment in the community through the viage heath post, dispensaries and Heath Centers (HCs). A we functioning PHC is of importance, since it might be the ony heath care service that is avaiabe for a arge part of the citizens. In addition, it is aso the main ink to other and more advanced heath care services avaiabe in the country. Through heath sector reforms and wide sector approaches the Government of Tanzania has achieved many important miestones in its endeavors to improve heath services. Decentraization processes as we as efforts on strategies and different guideines have focused on better utiization of resources and aso on improved quaity of heath services provided to the citizens. However, indications suggest that there are probems in the HCs performance. There is a ack of knowedge on how we they perform, and there are reasons to beieve that avaiabe resources are not aways effectivey distributed and efficienty utiised. There are aso indications of probem in the administrative structure. Preiminary findings indicate significant shortcomings in management and monitoring of the HCs at severa administrative eves. This might be viewed in the context of the existing system for funding heath care services. Based on the independent technica review of heath service deivery at district eve, the review team highighted cient perception regarding ong waiting time in heath faciity. 1 There were aso minima evidences that performance measuring ike workoad was taken into account for staff depoyment. The Controer and Auditor Genera (CAG) under section 28 of the Pubic Audit Act No. 11 of 2008 has the mandate to carry out Performance Audit 2 for the purpose of estabishing the economy, efficiency and effectiveness of any pubic expenditure or program. Performance auditing aims at examining whether the Government 1 Heath Research for Action(HERA), March Sometimes caed Vaue for Money Audits or shorty VFM Audits 4 A performance Audit Report on the Management of Primary Heath Care Performances

13 Ministries as we as the Regiona, Loca authorities and Pubic Authorities are doing the right thing and doing this in the right and east expensive way. Based on the above said probems the CAG has decided to conduct a performance audit on whether there is an effective distribution and efficient use of avaiabe resources for PHC in the country. 1.2 Purpose of the audit and audit questions The purpose of the audit is to examine whether HCs are managed efficienty and whether their performance is being measured and appropriatey considered in aocating the avaiabe resources. The aim is to find room for improving the management and efficiency of the HCs services to the citizens. The audit has focused on HCs owned and managed by the Government of Tanzania Mainand. The consideration is on how we the mechanism of measuring and evauating the performance is inked with the aocation and utiization of the avaiabe resources for existing HCs in Tanzania mainand. This report provides the resut from appying the foowing three audit questions: 1. Do the Councis manage heath centers performance efficienty; do they use appropriate means to safeguard that avaiabe resources are distributed effectivey and thereafter utiized efficienty? 2. Do the Regiona Secretariats efficienty monitor and evauate heath centers performance at Counci eve; do they provide the centra government with appropriate information and feedback? 3. Do the Centra government authorities appropriatey address mentioned issues are significant actions taken to improve the situation? 1.3 Audit design Scope and imitation of the audit The audit focuses on Loca Government Authorities which are responsibe for a matters pertaining to PHC services as mandated by the Loca Government District Authorities Act of 1982 and the Loca Government Urban Authorities Act No. 8 of 1982 as amended the Loca Government Urban Authorities Act No. 6 of To answer the audit questions a number of sub-questions have been formuated. A major centra government authorities with duties inked to PHC have been contacted in order to find out what they are expected to do, what they are doing and how they view the situation. Recipients of services were not interviewed. A performance Audit Report on the Management of Primary Heath Care Performances 5

14 The audit team chose a imited number of regions, Councis and heath centers (HCs) for coser examination. The seection is not based on random, since the purpose is not to present a scientificay vaid genera picture but to answer the audit questions above with a reasonabe degree of assurance. Experts in the fied have provided vauabe information on how to seect sampes that are sma but sti aow for reasonabe concusions. One must have in mind, that figures under this study represent a imited number of HCs and that it ony provides a picture at a given point in time. However, Experts and stakehoders in the fied have to a arge extent confirmed that there are huge and yet not fuy examined differences in workoad among HCs in Tanzania. Seven regions of various sizes and popuation and with reasonabe accessibiity were chosen. The aim was to incude regions with different conditions. The regions seected were Dodoma, Iringa, Morogoro, Lindi, Coast, Tanga and Mtwara. In short, the seection covers one third of the regions in Tanzania mainand. According to experts, this ought to be enough for the audit. A these regions were visited by the audit team. In each of the seven regions, a number of Councis were seected for examination. In few regions a Hcs in seected Councis were chosen to see whether there are differences in management and performance within the same region. Otherwise, ony a few Councis from each region were chosen. In tota, 20 Councis out of Tanzania s 133 Councis were seected (to match the requirements that the margina error shoud be ess than 10 %). The Councis were chosen to represent various externa conditions, ike: Geographica: Rura and urban Councis Statuary: City Councis, municipa towns and districts Economic: Richer and poorer Councis Popuation size: Big and sma and various demographic features The audit team interviewed management in a twenty Councis in order to study how they fufi their tasks and promote good performance among HCs. Government owned HC s were seected for examination of workoad, waiting and processing time (WPT) and some other management aspects. In tota, 32 HCs were seected and visited. This means that 40% of the seected Councis were fuy covered 3. The sampe size the 32 HCs was seected based on simiar consideration as above (to find a minimum sampe size required for desired anaysis). According to the avaiabiity of data of workoad and WPT, out of the 32 HCs, 30 Hcs were further anaysed. 3 A HCs faciities owned by Government in the said Councis were visited 6 A performance Audit Report on the Management of Primary Heath Care Performances

15 The seected sampe of 32 HCs represent amost 10 % of the (331) HCs in Tanzania Mainand. 4 Tabe 1: Summary of samping of different categories of popuation chosen in Tanzania Mainand S/N Categories Popuation Sampe seected Sampe Anaysed % of coverage 1 Regions Councis HCs Methods and impementation In undertaking the audit, various methods of data coection were used in order to answer the audit questions. The methods used incude the foowing: 73 interviews with representatives of the operating eve, the different administrative eves and reevant categories outside the PHC system review of various documents reated to heath sector direct observations at the studied HCs and Councis data coection of working conditions in terms of workoad as we as waiting and processing time at the studied HCs 5. The audit invoved discussions and documents review at nationa, regiona, counci and HC eves. 6 The data coection task was done in two phases. The first phase covered Dodoma, Iringa, Morogoro and Tanga regions whie the second phase covered Coast, Lindi and Mtwara regions. 7 Information was coected from various sources and stakehoders in order to take a wide spectrum of perspectives and arguments. 8 At centra eve various staff concerning financing and administering of heath activities were interviewed. At regiona and counci eves, Regiona Heath Management Teams (RHMTs) and Counci Heath Management Teams (CHMTs) were interviewed respectivey. 4 The seection of 32 HCs based on the isted 331 HCs mentioned in the Annua Heath Statistica Abstract of Apri See Appendix 20 and 21 6 See reference ist for documents reviewed. 7 The second phase came after stakehoders meeting where by the team was tod to increase the scope so as to add more information and more HCs in order to get a comprehensive and baanced picture. 8 See ist of persons being interviewed. A performance Audit Report on the Management of Primary Heath Care Performances 7

16 Externa experts and research scientists as we as managers and staff and representatives from the fied and some NGOs were interviewed. Managers of HC s or their representatives were aso interviewed, by teephone or through visits. It has often but not aways been possibe to verify oray provided Information and statements. This broad approach heped us in obtaining vita information and provided a number of opportunities to exchange views and arguments. It aso heped interpreting data and anayzing things from different perspectives. Both officia and unofficia documents from different sources were studied. It has not aways been possibe to check the quaity of the information in detais. If there were reasons to beieve that the quaity was not what it ought to be, the information has not been used. Aternativey, comments on the quaity are provided. Another method used in gathering information is direct observation. Information on waiting-processing time (WPT) and workoad was coected by this method. 9 The method was time-consuming, but necessary to be abe to get reiabe and independent data. However, the presence of the observer of WPT was known to the staff of the HCs during observation. This was unavoidabe due to the nature of the exercise. Aso there was a ess separation of duties between management and operating staff of the HC. The data gathered provide a picture of working conditions and service deivered to the visitors 10 at the HC at a given point in time. The data is sufficient in answering the audit questions, but it does not aow for concusive statements for a HCs. The MoHSW is responsibe for deveoping human resources poicies and strategy for training. However the shortage of heath staff is critica in terms of quaification and mix. According to the Human Resources for Heath strategic pan, the shortage of professiona staff in the HCs for the year 2006 was 59%. The audit team focused on the use of avaiabe staff in the visited heath faciity i.e 41% 11. During the audit, experts and stakehoders in the fied were abe to discuss the methods used and findings at meetings with a focus group. These meetings provided vauabe information to the audit team. A draft report was examined by an independent externa reviewer. Before finaizing the report, it has been sent to a major auditees (PMO-RALG and MOHSW) for facts cearance process. 9 WPT refers to the tota time spent by a visitor at HC from arriva to exit, and workoad refers to the average number of visitors at HC per day per futime working medica staff. For more detaied information see Appendix Visitors refers to the cients/patients ooking for heath service to the HCs 11 MoHSW Human Resource for Heath Strategic Pan issued January A performance Audit Report on the Management of Primary Heath Care Performances

17 1.4 Structure of the audit The report is divided into seven Chapters. These are as foows: Abbreviations are expained the first time they are used in the text. A ist with a used abbreviations is avaiabe after the preface. A performance Audit Report on the Management of Primary Heath Care Performances 9

18 Chapter Two Description of the Audit area The concept of PHC was officiay aunched in 1978 in the Ama Ata Conference (WHO, 1978) as the key strategy for achieving the WHO s goa of heath for a. PHC and decentraised district based heath system were part of the strategy to address issues of equity and accessibiity of heath care services in deveoping countries. 12 Tanzania had aready started impementing the goa of heath for a after the Arusha decaration of In 1983, the Ministry of Heath issued guideines on the impementation of PHC in the country. Primary Heath Care services form the basement of the pyramida structure of heath care services. This is provided by a number of dispensaries, HCs and District hospitas at the district eve. The basic requirements of PHC are as foows: Community Invovement Cooperation with other sectors Decentraisation 2.1 The heath care poicy The Nationa Heath Poicy aims at impementing both nationa and internationa commitments. The vision is to have a heathy community that can contribute effectivey to individua deveopment and to the country as a whoe. The mission is to faciitate the provision of basic heath services which are proportiona, equitabe, of high quaity, affordabe, sustainabe and gender-sensitive. 13 Goas and objectives The goas of the poicy are to safeguard and improve the heath and we-being of a the peope, with a focus on those at risk and to put in pace a heath system that wi meet peope s needs and contribute to increase ife expectancy. These aims are assumed to be achieved through PHC. Good heath i.e., physica menta and socia we being is seen as a major resource for economic deveopment. 14 The Tanzanian government took deiberate efforts during the two decades of post independence to aeviate some historicay inherited inequities, introducing, for exampe, free heath services. The process of free provision of heath services, 12 Kimaro C. & Sahay S. An institutiona perspective on the process of decentraization of heath information systems: A case study from Tanzania. WHO, 1994; Braa & Hedberg, 2002; Sandiford et a., 1992) 13 Tanzania Service Provision Assessment, Primary Heath Care Strategy, A performance Audit Report on the Management of Primary Heath Care Performances

19 however, suffered, during the eary 1980 s due to many issues. Consequenty, the country adopted new socio-economic poicies such as the Word Bank s structura adjustment programme and introduced the pubic sector reforms. The heath sector reform programmes, which started in 1994, focused mainy on decentraization of heath services by taking on board both manageria and financia reforms. One of the objectives is to improve access, quaity and efficiency of primary heath services at district eve. Heath Sector Strategic Pan The present, second, Heath Sector Strategic Pan (HSSP) covering the period Juy 2003 June 2008 focuses on provision of equitabe quaity heath services and cient satisfaction. 15 This can, according to the Strategic Pan, be reaized through Improved management of district heath services and services deivery using the Essentia Heath Package (EHP). Improved avaiabiity and utiization of resources i.e. personne, drugs suppies and equipments. Improved communication and transport between different eves of the heath services pyramid. Introducing performance based incentives and staff benefits inked to service deivery. 2.2 Roes and responsibiities There are a number of key payers who faciitate the whoe process of providing heath services to the citizens. The roes of the heath sector are executed at the nationa, regiona and counci eve, which aso is the operating eve Centra government authorities reguators and supervisors The actors at the nationa eve have infuence on the HCs performance both as actors from nationa eve and as system supervisors. Their roes among other things are poicy making, deveoping standards and guideines, coordination and supervision. The Ministry of Heath and Socia Wefare (MoHSW) is responsibe for deveoping poicies and standards for PHC. The ministry has deveoped and decided on the Loca Government and Heath sector reforms. The Nationa Heath Poicy has aso been reviewed and a number of coaborative forums have been conducted Comprehensive Counci Heath Panning Guideine, February Coaborative forums incudes Basket Financing Committee, Sector Wide Approach (SWAP), Technica and Annua Heath Joint Technica Review meetings carried out by the PMORALG and MoHSW aiming at improving heath services. A performance Audit Report on the Management of Primary Heath Care Performances 11

20 These reforms incude formation of Heath Sector Management structures at different eves as we as monitoring and evauation toos. These toos incude assessment criteria for among other things progress reports and guideines for supervision. The MoHSW aocate drugs (pharmaceuticas and medica suppies). Drugs and medica equipments are distributed through the Medica Stores Department (MSD) which is under the MoHSW. The ministry aso faciitates the PHC services with technica advice, support and with monitoring of, among other things, disease patterns and the quaity of heath services. The Prime Minister s Office Regiona Administration and Loca Government (PMO- RALG) deas with the impementation of the heath poicies. This task incudes monitoring of the use of funds and aso administration of human resources at the regiona and counci eves. The PMO-RALG aso has a coordinating roe by inking a Regiona Administrative Secretaries (RAS) and Loca Government (Councis) in Tanzania Mainand Regiona authorities evauators and supervisors At the Regiona eve, the Regiona Secretariats (RS) is an extended arm of the MoHSW and the PMO-RALG at the centra eve. Among other things the RS pays the roe of: Supporting the heath service deivery through the Regiona Heath Management Teams (RHMT) Assessing Counci Heath Pans as we as its impementation reports (technica and financia reports) Monitoring and supervising the Counci Heath Management Teams i.e. CHMT and advice them accordingy. Provides the centra eve with information for decision making Loca authorities operationa managers and service providers PHC services operate under Loca Government Authority whose mandates are derived under the Loca Government Urban Authorities Act No. 8 of and the Loca Government District Authorities Act. The functions of both the City and Municipa Councis are provided for in Section 7A of Act No. 8 of One of their functions is to improve and maintain quaity heath service for the residents. According to the above function, the Councis are responsibe for managing a government owned HCs in their respective area. The Councis manage the HCs through the operating team, Counci Heath Management Team (CHMT), headed by the Municipa- or District Medica Officer 17 Amended with Loca Government Urban Authorities Act No. 6 of Amended to Section 69A of Act No. 6 of A performance Audit Report on the Management of Primary Heath Care Performances

21 (DMO). At counci eve the Heath Management Information System (HMIS) requires each HC to report quartery and annuay to the DMO. See Figure 1 beow. Figure 1: Heath System in Tanzania Source: Interviews and document review Each counci is responsibe for monitoring and evauation of performance of its HCs. Information from HMIS and supportive supervision are the major toos in assisting the Councis with monitoring and evauation of HCs performance. The HMIS is a system used for coecting data from heath faciities reating with activities of various heath programmes and heath care services. These data are aso reported to higher, administrative eves 19. Apart from these various categories of data coection, the system aso incudes schedues which require the heath staff at the HCs to report workoad to the Councis. This reporting of workoad impies the tota number of visitors of various categories divided with the empoyed number of heath staffs at the HC. 20 Supportive supervision is done by the CHMT in order to assess performance of the HCs. This supervision is aso carried out with the aim of guiding, supporting 19 Data coected reates with Community outreaches, drugs and medica suppies, Outpatient Department, Antenata, Chid, Famiy panning, Diarrhea Treatment Corner (DTC), Denta, Laboratory and meases immunization. 20 The HMIS book 2 page 9 schedues 7 require the computation of workoad per day. The objective is one heath staff to serve patients per day. There is no big difference between empoyed and present staff at HCs visited A performance Audit Report on the Management of Primary Heath Care Performances 13

22 and assisting heath providers in carrying out their assigned tasks. The purpose of supportive supervision is to focus on probem soving as an approach in order to improve quaity and to meet cient needs. The aim is aso to strengthen heath workers performance in reation to quaity and standards and to identify gaps and to address them. According to the MoHSW, the aim is aso to promote quaity outcomes. This is done by strengthening communications, faciitating team work and supporting heath providers in impementing, monitoring and improving their own performance. The Supervision Guideines requires the CHMT to conduct at east one visit per quarter in each heath faciity Counci Heath Service Boards (CHSBs), This is an executive organ of the counci for supervising and controing a heath activities and resources. The Board is aso responsibe for impementing a poicies given by the Ministry of Heath to improve the working environment and remuneration of heath workers. The board is expected to buid good reationship with other sectors and deveopment partners in the heath sector to poo resources in a sustainabe manner 21. CHSBs incuding the Medica Officer, a CHMT representative, community and NGO representatives, and private hospita representatives, provide a muti-stakehoder forum promoting oca participation and diaogue; CHSBs assist the CHMT with the preparation of comprehensive counci heath pans Heath Faciity Committees (HFC) HFC provide a consutative forum aimed at ensuring community participation in the management of individua faciities. The roes of HFC among other things incude overseeing the genera operations and management of the heath faciity and faciitating a feedback process to the community pertaining to the operations and management of the heath faciity. 2.3 Funding PHC is financed mainy by the government and the donors through bock grants and heath basket funds (HBF) respectivey. 22 Other sources of finance incude cost sharing, community heath funds and Nationa Heath Insurance. The bock grants from the government are mainy used to finance saaries for a fu time heath staff empoyed by the Councis and Other Charges. 21 RS/RHMT Training Modues in support of Counci Heath Management Team Modue One: Heath Sector Reforms and Panning 22 The Comprehensive Counci Heath Pan Guideine provide direction on how the resources at the counci are managed as we as the guidance on formuating budget based on NEHP and assessment of executed panned activities performance. 14 A performance Audit Report on the Management of Primary Heath Care Performances

23 Heath Basket funds from deveopment partners (donors) are the major sources for financing the operating activities concerning the provision of heath services to citizens. Funds for Drugs are money from both the Government and the donors (Bock Grant and HBF). These resources are aocated from the MoHSW to the Medica Stores Department (MSD) for financing procurement of medicines, medica equipment and suppies at the HCs. Disbursement mechanism for both heath bock and basket fund foows government procedure. However, condition for disbursement of HBF is different from heath bock grant. Beow is an outine of the fund aocation Aocation of Heath Bock grant (HBG) Bock Grants are directy reeased to the Loca Government s Authorities (LGA) by the Ministry of Finance and Economic affairs (MoFEA). The aocation of HBG foows the norma government procedure whereby the approved budget is aocated to the counci as requested by PMORALG from MoFEA. The PMORALG notifies the RS for foow up. The aocation to the counci is based on a formua in which the foowing factors are considered: Popuation (70%) Poverty count (10%) District Medica vehice route (10%) Under-five mortaity (10%). Figure 3: Disbursement of Bock Grant Source: Interviews and document review. A performance Audit Report on the Management of Primary Heath Care Performances 15

24 Counci s staff are paid their saaries from the bock grant (persona emoument). The Councis have mandate to empoy heath staffs using the Bock Grant after getting permission from the President s Office-Pubic Service Management. For each HC there is a Staff Estabishment, the so caed IKAMA 23 issued by the MoHSW and PO-PSM with a proper mix of 29 heath staff per each HC. The Councis then have the power to aocate and reaocate the avaiabe staff between the HCs within their area Aocation of Heath Basket Funds (HBF) HBFs are disbursed by the MoFEA after an approva of the Basket Fund Committee. Aocation is based on the formua of Popuation (70%), Poverty count (10%), District Medica vehice route (10%) and Under-five mortaity (10%). RS review progress reports and submit assessment report to the PMORALG. PMORALG recommends to the BFC, councis to be funded and give reasons for those not to be funded either for non submission of CCHPs and/or progress reports or shortfas discovered there from. At Counci eve HBF is aocated in a range of percentage per cost center. There are six cost centers in the CCHP Guideine 24. One of them is serving the HCs which are supposed to get 15-20% of the tota Counci s HBF budget aocated for the Counci s impementation of activities at this eve. The DMO provides the HCs with goods and services (technica support) whie the HCs provide heath service to the citizens. These resources are directed for the HCs services as seen in Figure 2 and 3.Figure 2 shows a system graph for the disbursement of funds. Figure 2: Disbursement of Heath Basket Fund system graph Source: Interviews and document reviews 23 Standard staffing eve 24 Other cost centers incude Office of DMO, Counci Hospita, Vountary Agency Hospitas, Dispensary and Communities. 16 A performance Audit Report on the Management of Primary Heath Care Performances

25 2.3.3 Aocation of Funds for drugs and Medica Suppies The Funds for Drugs are aocated annuay from the MoHSW to the Medica Stores Department (MSD) based on anaysis for each HC. The MSD then pays the roe of procuring, storage and distribution of the required and approved drugs as per HCs, request. 25 This is iustrated in Figure 4. Figure 4: Aocation of funds for Medicine and Medica Suppies to HCs Source: Interviews and document reviews 25 Most of HCs visited order their drugs from MSD on quartery basis through ordering system which known as Integrated Logistic system (ILS). A performance Audit Report on the Management of Primary Heath Care Performances 17

26 Chapter Three Heath centers performance The main issue in this audit is whether the HCs are managed efficienty and whether the HCs performance is being measured and appropriatey considered in aocating the avaiabe resources. This chapter concerns the aspects of efficiency and effectiveness of the HCs performance as we as information reated with the causes and expanations of the output of this performance. The examination is based on studies of the performance at the HCs in terms of workoad and waiting and processing time. 26 The examination is aso based on interviews at the Councis eve and the HCs as we as reports issued by the Councis and the HCs. This chapter deas with two main issues. One issue concerns funding and workoad at the HCs. The other issue concerns aspects of efficiency and effectiveness of the HCs performance. 3.1 Funding and workoad The audit team has studied 30 HCs with respect to funding, workoad and waiting and processing time. The first step was to study funding and workoad The workoad varies but is mosty not so high Workoad is used to describe reations between demand for heath care services and abiity to meet those demands. It coud be measured in different ways. In this study it s measured by the number of unschedued visits (visitors) to the HCs in reation to the human resources. More precisey, it refers to the average number of visitors at the HC per day and per fu time working medica staff. By measuring workoad one gets a picture of the reation between the extents of the activities at the HCs in reation to the amount of human resources aocated for these activities. According to HMIS standard 27 set, the average workoad range from visitors per day. The workoad has in this case been measured by direct observation, during two reguar working days and some by interview and review of documents 28. It provides a picture of the workoad in that given time. 26 For further information see section The standard need to be reviewed as the HMIS is aso outdated HCs were visited and 30 HCS were anayzed ( Refer appendix 15) 18 A performance Audit Report on the Management of Primary Heath Care Performances

27 Photo 1: Congestion of visitors in one of the heath faciities According to the study, the workoad varies significanty among the HCs. In this study it varies from 1 to 23 visitors per day and fu time working staff among the studied HCs. As shown in Tabe 2 beow, a great majority of the HCs (80 %) had ess than ten visitors, and ony two HCs had a workoad of 13 visitors or more. Tabe 2 raises the question on the aocation of resources. Few HCs seem to have more work, whie others have a rather ow workoad. Tabe 2: Number and percentage of HCs with their respective workoad Workoad (Number of visitors per day per staff) Number of HC Number % Tota Sources: Auditor s Physica observation, interviews and document reviews The above findings suggest that the demand for services the number of visitors is not proportiona to the aocation of human resources. The majority 80% of the A performance Audit Report on the Management of Primary Heath Care Performances 19

28 HCs have 1-9 visitors per day per staff, i.e. a ow workoad whie the remaining few (6) have to strugge with a higher workoad The resources for Drugs are basicay the same at a HCs Ideay, resources for drugs shoud correspond to the needs or somehow refect the number of visitors (given fairy simiar externa conditions and demands). Even so, it s difficut to deny the fact that resources for Drugs are basicay the same for a HCs. Our data indicates HC with the argest numbers of visitors had fewer resources for drugs, than those with few visitors (compare for instance the HC in Kiimarondo, with 18 visitors per day, and the HC in Makorora, with more than twenty times as many visitors per day). This is shown in Tabe 3 beow. Tabe 3: Visitors, workoad and funds for drugs at HCs a comparison Name of HC Average number of visitors per day at the HC Workoad (Average visitors per day per staff) Funds for Drugs aocation per Quarter (TSH) Ngome ,000,000 Kiimarondo ,000,000 Makorora ,755,000 Chihangu ,000,000 Mandawa ,000,000 Chainze ,000,000 Sources: Data coected through observation, interviews and document reviews The MoHSW uses a formua for the aocation of funds (deposited at MSD) for the different eves. This formua has severa arbitrary aspects and does not take the actua workoad or performance of each heath faciity into account, nor oca Burden of Disease (BoD) or poverty indicators. This formua does not expain the variations noted in the PER. 3.2 Workoad and time for waiting and processing Waiting and Processing Time (WPT) refers to the tota time spent by the HCs visitors from their arriva to their exit from the HC incuding time for treatment. An examination of WPT provides a picture of the HCs performance. One criterion of service deivery efficiency is high workoad combined with quick service deivery. However, the MoHSW has not yet estabished visitor expected waiting times. Other country ike Mata had pubished Quaity Service Charters (QSC) for HCs. The Foriana HC in the said country had issued QSC in 1999 with visitors expected waiting time of 30 minutes to be seen by Genera Practitioner (GP) whie Qormi HC had in the year 2000 pubished QSC with expected waiting time of up to one hour Auditor Genera of Mata, performance audit report on primary heath care (the Genera Practitioners functions within Heath Centers), A performance Audit Report on the Management of Primary Heath Care Performances

29 Photo 2: Visitors waiting for the services at the heath faciities Waiting and processing time varies among HCs Ideay, the waiting time shoud not vary much among HCs (uness there are poicies saying that citizens do not have the right to equa eve of service). In our study, however, the differences are significant, even though the proportion of HCs with a high average WPT, is sma. On a scae from 1 to 181 minutes or more of WPT most of the HCs are on the ower part of this scae. A visit at a HC doesn t ast more than one hour for haf of the examined HCs and ess than 40 minutes for amost one third of them as seen in Tabe 4 beow). Tabe 4: Number and percentage of HCs with their respective waiting time Waiting and processing time (Minutes) Number of HCs Number % Source: Auditor s physica observation A performance Audit Report on the Management of Primary Heath Care Performances 21

30 3.2.2 Variation in efficiency among HCs Efficiency can be measured in different ways. In this study, we found reevant to measure efficiency by comparing workoad with WPT. Units with simiar conditions in terms of simiar service and equa workoad are expected to have the same WPT. If that is not the case, it s common to seek expanation amongst interna factors such as management, competence, organization etc. According to this investigation, the HCs performance varies significanty. WPT varies significanty even when the workoad is the same. And differences in workoad are not aways refected in WPT, even if there is an overa ink between them. It s hard to beieve even by experienced anayst consuted that externa factors (or factors reated to the design of the study) may expain more than some of these differences. Long time for service deivery is not ony due to high workoad, and high workoad does not excude a short WPT. This is iustrated in the Tabe 5 beow. Tabe 5: Workoad compared with waiting and processing time Name of HC Workoad (Average number of visitors per day per staff) Waiting and processing time (WPT) (Minutes) Meea 3 75 Mndemu 4 16 Nkowe Njinjo 9 17 Nagaga Chamwino Mahuta Chainze Source: Auditor s physica observation, interviews and document reviews This can be visuaised as beow: 22 A performance Audit Report on the Management of Primary Heath Care Performances

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