Contents. The Tanzania Private Health Sector Assessment Report: we will achieve more if we take PPP seriously TANZANIA. Africa Health Tanzania 1

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1 Contents 02 Current Initiatives in health certification and accreditation Dr Edgar Lusaya, Head,Quality Improvement Programme, APHFTA 03 Shifting the health-seeking behaviour: from traditional care and treatment to prevention practices Elinath Mtango, Head of Membership Services, APHFTA 04 East forms a regional health forum Dr Samwel Ogillo, Co-Editor, Africa Health (Tanzania) 05 The premium rush towards 2015: where are we in the Millennium Development race? Dr Mariam Ongara, Head of PPP at the MoHSW, Tanzania 06 East Africa starts walking the talk on social protection for health Dr Samwel Ogillo, Co-Editor, Africa Health (Tanzania) 08 Reaching the rural population with essential medicines Jafar Liana, Senior Technical Advisor, MSH, Tanzania The Tanzania Africa Health pages are coordinated by the editorial board members listed below. Suggestions for articles, news stories, or letters are welcome and should be submitted directly to them. If you wish to comment on the core journal, communicate to the UK address listed on the main contents page. Distribution is free, and by hand. If you wish to be sure of receiving a copy for either yourself or your institution, please subscribe. See page 3 of the main journal for details. Subscribed copies will be personally addressed, and posted. Editors Dr Samwel Ogillo Association of Private Health Facilities in Tanzania (APHFTA) Tel: ogillo@aphfta.org Dr Oberlin Kisanga GTZ, Tanzania Tel: ome.kisanga@gtz.or.tz Dr Adeline Kimambo Christian Social Services Commision (CSSC), Tanzania Tel: akimambo@cssc.or.tz The Tanzania Private Health Sector Assessment Report: we will achieve more if we take PPP seriously Healthcare stakeholders in Tanzania met in November 2012 at a workshop to disseminate the findings of the Tanzania Private Health Sector Assessment that was carried out between June and September The assessment was conducted by SHOPS (Strengthening Health Outcomes through the Private Sector) and IFC, and funded by USAID, DANIDA, IFC, and the Ministry of Health and Social Welfare. The Assessment confirmed that: The private health sector in Tanzania is diverse and is involved in almost all health system building blocks through: (a) delivery of healthcare, including priority health services important to MOHSW; (b) manufacturing, distributing and retailing medicines; (c) training health professionals; (d) providing/purchasing health services for employees; (e) the private health sector is growing in size and dynamics; (f) the private health sector can be found everywhere, in both urban and rural extensions (g) the private health sector serves both the rich and the poor (h) the private health sector is open to partnering with the MOHSW to improve health for all. The Report further noted that there was a significant change in government mindset towards working with the private health sector. There was no longer if we should attitude but how can we work with the private sector attitude. The report also showed political commitment from different government areas, namely the Ministry of Health and social Welfare, the Prime Minister s Office, and the Ministry of Finance. The Policy framework is in place as well as institutional structures to enable a stronger collaboration between the private health sector and the public sector through public private partnership initiatives in health. The challenge ahead is in translating the policies and the strategies into action. Tanzania is set to achieve more if we will commit ourselves to working together in strengthening the healthcare system of our country through PPP initiatives aimed at achieving the national goals as well as the millennium development goals (MDGs). The Editors, Dar es Salaam Novemberr 2012 Africa Health Tanzania 1

2 Current initiatives in health certification and accreditation Measuring quality of care is moving up the agenda. Dr Edgar Lusaya outlines a step-by-step approach that APHFTA has introduced Quality improvement in healthcare services has become an important element in healthcare delivery in most of the developing countries like Tanzania. For one to understand if there is an improvement there should be a systematic process to measure the baseline performances, identifying gaps, and working on a plan to bridge the gaps identified. But how do we know if there is a gap? Definitely the baseline performance levels should be compared with the set standards! Therefore, it is a process. If there is an improvement in the next assessment without any mechanism in place to bridge that gap, that is a fluke or coincidence. It is high time to institute scientific measures which will re-assure constant results. Studies have shown that recognition mechanisms in the form of certification is an efficient way for facilities to disclose quality information and ultimately to start quality improvement programmes and initiatives. This surpasses old ways of facility inspections. Staffs of a healthcare facility asked the facility s owner to get enrolled into an accreditation programme because if the facility was accredited their CVs would be more impressive and they would feel proud of their success. Certification and accreditation programme supported by APHFTA APHFTA has partnered with the Safe Care stepwise quality improvement programme to improve the quality of care for the private healthcare sector in Tanzania. The programme is linked with recognition mechanism for each level attained. The standards are divided into 13 service elements. There are five levels of improvement, each level has a defined score range. Service elements The service elements in the Safe Care Standards are: A. Healthcare organisation management Management and leadership. Human resource management. Patient rights and access to care. Management of information. Risk management. B. Care of patients Primary healthcare services. In-patient care. Dr Edgar Lusaya is the Head of the Quality Improvement Programme at the Association of Private Health Facilities in Tanzania (APHFTA). A Tanzanian Ministry of Health and Social Welfare Official, Dr Lulu Sawa, presenting a certificate of attendance to a healthcare provider after 3 days training to improving the quality of care delivered by healthcare facilities C. Specialised services Operating theatre and anaesthetic services. Laboratory services. Diagnostic imaging services. Medication management. D. Ancillary services Facility management services. Support services. The Safe Care standards A web-based quality information system (CoQIS) is used to capture quality information. The system measures at baseline the situation in a healthcare facility, identifies deficiencies, prioritise interventions, and monitors improving compliance levels with standards at individual facilities and across a group of facilities. The benefit of this stepwise approach is that it encourages facility staff to continue with quality improvement activities. The structure and organisation of these standards meet the requirement set by ISQUA (The International Society for Quality in Healthcare). They are intended for use by healthcare organisations in resourcerestricted setting in Africa. The ultimate goal is to have an independent evaluation team to assess how well the standards are met (Accreditation). It is therefore important to recognise an organisation s achievement as it moves from one step to another (step one being the lowest and step 5 being the highest). Thus progress 2 Africa Health Tanzania November 2012

3 TANZANIA in meeting these standards will bring recognition for incremental achievement (certification). Making sure the systems are in place for quality improvement A structured system is in place to make sure facilities attains upper scores than the baseline survey assessment. This is done through trainings, formulating quality improvement plans, and doing monitoring visits which are also meant to provide onsite coaching and support. The improvement plans are developed on the basis of prioritisation of the criteria which bears more weight than others. Facilities are encouraged to put up quality systems to ensure quality management implementation. Setting up and actively engaging a quality teams is only one of the components. Other components are documentation of activities and corrective and preventive actions (kappa). Conclusion In resource-restricted settings like Tanzania, the step wise approach in quality improvement can help motivate facilities to improve the quality of care that they deliver. They may not reach accreditation, but each measurable milestone can be appreciated and used as a springboard to advance to the next higher level. Shifting the health-seeking behaviour: from traditional care and treatment to prevention practices Elinath Mtango on a wellness initiative with children in Dar es Salaam Seeking care and treatment has always been common practice by both healthcare providers and patients. Most people visit a health facility as soon as they feel ill. This practice has contributed to many avoidable deaths and morbidity as some illnesses do not display symptoms until later stages, by which time it is often too late. As part of a campaign to change health-seeking behaviour at the community level, the Association of Private Health Facilities in Tanzania (APHFTA), through its Dar es Salaam zone, organised a free children s camp. The objectives were to conduct full body examinations to determine any health problems and provide essential advice; and where necessary provide referral to a health facility for further diagnosis. Some of the diagnoses conducted included examination of eyes, ears and throat, and a dental check. All children were checked for Body Mass Index (BMI). Over 80 children aged between 3 and 9 years attended the event escorted by parents and guardians. Some of the APHPTA members,such as the TMJ hospital and the Tanzania Occupational Health Services, also provided medical staff and equipment to support the event. Along with medical checkups, the camp also organised sports events as a strategy to help the children interact and also to examine their mental and physical health. Some of the identified health problems during the camp included low BMI, umbilical hernia, tineacapitis, dental caries, anaemia, mild pallor and cataract. Seventeen children were referred to hospital for further diagnosis and treatment. Elinath Mtango is Head of Membership Services at the Association of Private Health Facilities in Tanzania (APHFTA). Novemberr 2012 Africa Health Tanzania 3

4 East forms a regional health forum Samwel Ogillo reports on the inaugural meeting called by business and civil society leaders which took place in Arusha On October 30 th 2012 in the city of Arusha the East African Business Council (EABC) and the East African Community Civil Society Forum (EACSOF) the regional apex associations for the private sector and civil society respectively agreed to promote and facilitate the management of health delivery systems and better planning mechanisms that will enhance the efficiency of healthcare services within the East African Partner States. The Treaty for the Establishment of the East African Community recognises private sector and civil society participation and cooperation in health promotion activities. Article 118 provides for joint action towards the prevention and control of communicable and non-communicable diseases. Article 127 of the Treaty encourages continuous dialogue with and participation of the private sector and civil society in the regional integration process. The EAC Development Strategy also emphasises economic co-operation and development, with a strong focus on the social dimension. The role of the private sector and civil society is considered as central and crucial to the regional integration and to the socio-economic development in a continuous partnership with the public sector. The private sector plays a critical role in delivering health services and pharmaceutical products throughout East Africa. In Kenya, the private sector owns almost two-thirds of all health facilities and is the largest employer of healthcare workers. The private sector provides about a quarter of all health services in Tanzania and about half of all services in Uganda. This situation is more or less similar in Burundi and Rwanda. While it varies from country to country, the private sector also trains large numbers of health workers across the region. In fact, the private sector dealing with health now provides half of all health services in the region to rich and poor alike. Private healthcare providers are often the only option for people living in rural regions and poor urban slums. National governments across the region and international partners are increasingly recognising that one of the key elements to better health service delivery is improving the way in which governments and the private health sector work together. More effective engagement between the public and private healthcare Dr Samwel Ogillo, Co-Editor, Africa Health (Tanzania) sectors in terms of better policies, regulations, information sharing, and financing mechanisms, including those for the poor, would not only improve the performance of East-African health systems. It would save lives. Civil Society Organisations (CSOs) contribute to enhanced healthcare by providing services in response to community needs and adapting to local conditions. They lobby and advocate for equity and pro-poor health policies, often acting as an intermediary between communities and government; they reach remote areas poorly served by government facilities and provide services that may be less expensive and more efficient. CSOs also provide technical skills on a range of issues from planning to delivery to services. They innovate and disseminate good practices to other non-governmental organisations (NGOs) or the public sector. CSOs also contribute to public understanding and enhance public information. This can build more effective interaction between services and clients and enhance community control over health interventions. It is in this regard that the East African Business Council (EABC) and the East African Civil Society Forum (EASCOF), the apex bodies for private sector and civil society organisations in East Africa, respectively, have initiated a joint action towards the establishment of a regional health forum comprising public, private sector, and civil society stakeholders. In recognising the overarching need to address common issues in key industry sectors, trade and investment, EABC spearheaded an initiative to mobilise, facilitate, and establish thematic platforms across the community. The platforms bring together national and regional stakeholders to dialogue on issues of mutual interest at regional level and build consensus on priority issues. It is against this background that the EABC and EACSOF organised the 1 st EAC Regional Health Stakeholders meeting on October th in Arusha to facilitate the establishment of the EAC Health Forum. Participants of the meeting included representatives from the East African Health Federation (EAHF), The East African Pharmaceutical Platform, The Federation of East African Pharmaceutical Manufacturers (FEAPM), The East Africa Network of AIDS Services Organizations (EANNASO), representatives from National Agencies for Medicines Procurement and Distribution, National Medicines Regulatory Agencies (NMRAs), East African Business Council (EABC), GIZ, and the EAC Secretariat Technical Staff. 4 Africa Health Tanzania November 2012

5 The premium rush towards 2015: where are we in the Millennium Development race? Dr Mariam Ongara provides an overview on the latest progress report Its 1134 days to reach 2015 where the Millennium Development Goals will be finally evaluated. According to the Health Sector Performance Report 2012, the trends towards MDG goals are encouraging. The health specific goals, particularly goal numbers 4, 5, and 6 have been given special emphasis in the Tanzania healthcare system. During the Joint Health Sector Annual Review meeting held on 16 th and 17 th October 2012, the health performance report displayed reassuring trends, particularly with the rapid drop in under-5 and infant mortality. Under-5 mortality has significantly dropped from 112 per 1000 live births in 2004/2005 to 81 child deaths per 1000 live births in 2009/2010; and projection to 2015 are at 64/1000 live births. Infant mortality has also been significantly controlled and currently they stand at 51/1000 compared with 68/1000 live births back in 2004/2005. By 2015 the infant mortality rate is expected to reduce to 38/1000 live births. Some of the contributing factors to the above achievements include increased immunisation coverage which has reached 95% country wide. The Integrated Management of Childhood Illness (IMCI) programme and use of insecticide-treated bed nets (ITNs) are other factors. However, significant challenges remain with maternal mortality. Despite dedicated efforts to reduce deaths related to childbirth, the rates are still unacceptably high at 454 while the projection for 2015 was 133/ The government has set forth to explore for more interventions. Malnutrition, low incomes for mothers to improve nutrition and afford better healthcare, complications due to HIV/AIDS, and limited transportation to healthcare facilities are among major constraints. Nevertheless, the government, in collaboration with other stakeholders, has not given up yet as the struggle continues to combat this challenge. The good news includes the decision by the government to engage the private health sector in these endeavours. About 37 district councils have already entered into service agreement with private health facilities to provide reproductive and child health services for free. The way forward is to scale-up this initiative so that more mothers are reached with better healthcare services. Our motto therefore remains that pregnancy is not a disease, so we should not let our mothers die just because they became pregnant. Dr Mariam Ongara is the Head of Public Private Partnerships at the Ministry of Health and Social Welfare, Tanzania Novemberr 2012 Africa Health Tanzania 5

6 East Africa starts walking the talk on social protection for health Dr Samwel Ogillo attended the conference in Kigali on the above topic and provides the following report East African Ministers of Health met in Kigali, Rwanda, on September 11 _ 12th at a conference to discuss social health protection in the East African Community (EAC). The conference focused on the efforts of EAC countries to provide social health protection (SHP) to their respective populations, their achievements and challenges, as well as provide recommendations on how to effectively support the development and harmonisation of SHP and SHP mechanisms in the EAC region. The conference ended with the signing of the Kigali Ministerial Statement on Universal Health Coverage and Long Term Harmonization of Social Health Protection in the East African Community. The Kigali conference highlighted various approaches for the development and implementation of comprehensive and equitable social health protection systems for the East African Community and to recommend policy options in developing regional mechanisms aimed at building a strong and harmonised system of SHP in the EAC. The conference contributed to the ongoing evidence-based approach of the EAC to meet social health protection needs of its population, as the region strives towards universal coverage and access to health services. The conference also provided a platform for: sharing of experience on best practices and exchanging ideas on challenges in the implementation of social health protection mechanisms in participating countries; identifying, assessing, and promoting the potential for integration of best practices and evidence into respective country contexts; consulting and elaborating recommendations on effective harmonised implementation of SHP and how to collaborate towards a stronger regional system of social health protection. Besides the East African Health Ministers, the Conference was also attended by key stakeholders of SHP in EAC partner states (Burundi, Kenya, Rwanda, Tanzania, and Uganda). This included government policy makers from health, finance, labour, planning and local government, East African Community officials, Samwel Ogillo, Association or Private Health Facilities in Tanzania EAC Ministers of Health meet in Kigali to discuss social protection national authorities, Social Health Protection/Health Insurance Organisations, representatives of health care providers, civil society, labour unions, academic institutions, and development partners. Social protection for health is critical to human welfare and sustained economic development and also contributes to global peace and security. In 2005, the World Health Assembly resolved that everyone should have access to health services without having to suffer from financial hardship in the process. This was reinforced by the 2010 World Health Report, Health Systems Financing: the Path to Universal Coverage and further by a 2011 World Health Assembly resolution, Sustainable Health Financing Structures and Universal Coverage. In some countries up to 11% of the population suffers from catastrophic medical expenses each year and up to 5% are forced into poverty. Despite progress achieved toward the health Millennium Development Goals, further efforts are required to ensure that individuals can benefit from the highest attainable standard of health and that good health can act as a driving force for economic and social development. Hence, during the high-level dialogue between Ministers of Finance and Health on 5th July 2012 in Tunis, one of the recommendations was to lay out the 6 Africa Health Tanzania November 2012

7 Delegates enter into lively debate at the conference path to universal health coverage for each country, in particular establishing mechanisms to ensure equitable access to essential health services including social health insurance. (World Health Report on Health Systems Financing, WHO Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector, 2012). Experiences of East Africa Community Member States in providing SHP varies some have well established compulsory, publicly managed, health insurance programmes, some of which include substantial transfers from general budget revenues, as seen in the case of Rwanda, with a health insurance coverage of over 90%. Some governments also fund services, often directly through the supply side, but others also use performance-based payment methods. Some EAC countries even have a robust private health insurance market. These differences highlight the fact that the specific path towards SHP/universal coverage differs from country to country; there is no single best solution that applies to all of them. However, best practices and lessons learned during the implementation process are important to be shared in order to improve EAC systems for SHP to meet each country s specific needs, but also to enhance harmonisation across the region. Ministers from all EAC countries took part Ministers sign the SHP Declaration Novemberr 2012 Africa Health Tanzania 7

8 Reaching the rural population with essential medicines Jafar Liana introduces an initiative to improve the quality of service provided by rural pharmacies Since 2000, the Tanzania Food and Drug Authority (TFDA), in collaboration with Management Sciences for Health (MSH), have been implementing the ADDO programe that aims to transform the existing drug shops (famously known as duka la dawabaridi) into accredited drug dispensing outlets (ADDO), through standards setting, training, business incentives, and regulatory enforcement. To begin with, the programme has put more emphasis in rural areas where small drug shops mandated to sell non-prescription medication are often the most convenient retail outlet from which to buy medicines for approximately 75% of the population living in rural and periurban communities More than 80% of the regions in Tanzania have been reached by the programme and to date there are 4041 functioning ADDOs while another 5853 are waiting to be accredited. Over dispensers have also received the training. The ADDO programme is now extending its scope to incorporate the following: access to artemisinin-based combination therapy and insecticide-treated nets; Jafar Liana is a Senior Technical Advisor at MSH, Tanzania integrated management of childhood illness; linking ADDOs to community-based HIV/AIDS palliative care and information; family planning; accreditation of ADDOs by national health insurance funds. With support from MSH/RPM Plus and the Mennonite Economic Development Associates (MEDA), TFDA targets to expand the model into other regions of Tanzania. The programme is co-financed by the Government of Tanzania, USAID, and DANIDA. Dispensing drugs: before accreditation (left) and after accreditation via the ADDO programme (right) Important contacts in Tanzania Permanent Secretary Ministry of Health and Social Welfa P O Box 9083, Dar es Salaam, Tanzania Tel: /7 Fax: ps@moh.go.tz National TB and Leprosy control Program Ministry of Health and Social Welfare P O Box 9083, Samora Avenue, Plot No: 37/38 Dar es Salaam, Tanzania Tel: Fax: tantci@intafrica.com, ntlp@moh.go.tz Tanzania Food and Drug Authority (TFDA) P O Box 77150, Dar es Salaam, Tanzania Tel: , , Fax: info@tfda.or.tz WHO (Tanzania country office address) P O Box 9292, Dar Es Salaam, Tanzania Tel: , , Fax: wrtan@tz.afro.who.int UNICEF Dar es Salaam Office UNICEF Building, Bibi Titi Street/Magore Road P O Box 4076, Dar es Salaam, Tanzania Tel: daressalaam@unicef.org The Association of Private Health Facilities in Tanzania (APHFTA) 55/644 Lumumba Street, P O Box 13234, Dar es Salaam, Tanzania Tel: /Fax : info@aphfta.org Christian Social Services Commission (CSSC) P. O. Box 9433, Dar es Salaam, Tanzania Phone: /Fax: info@cssc.or.tz Tanzania Commission for AIDS (TACAIDS) P O Box Dar es salaam, Tanzania Tel: , /Fax: ec@tacaids.go.tz Website: The National Institute for Medical Research (NIMR) 2448, Ocean Road, P O BOX 9653, Dar es salaam, Tanzania Tel: Fax: Africa Health Tanzania November 2012