Doctoral thesis
Tanzania, like many countries globally, has continuously been implementing health sector reforms with the intent of ensuring affordable health services to the population, in alignment with the shift towards Universal Health Coverage as well as improving the quality of health services, among these reforms has been the introduction of Direct Health Facility Financing (DHFF), which has limited evidence on its implementation and outcomes with respect to its intended goals. This study aimed to assess the implementation of DHFF in the Public Primary Health Facilities (PPHFs) as well as its effects on health system performance in Tanzania.
This study was conducted from January 2018 to September 2019 utilized a before and after non-controlled study design with a process evaluation embedded at midline. Both quantitative and qualitative methods were used for data collection. A structured questionnaire was used to obtain the quantitative data from exiting patients, and health care workers in 42 PPHFs. Qualitative data was collected using an interview guide through 14 in depth interviews and seven focus group discussions to health managers at council level from 14 councils in seven regions. Quantitaive data analysis was done using SPSS™ version 25 while for qualitative NVIVO QSR™ version 12 was used.
A total of 844 exiting patients were studied on seven domains of Health System Responsiveness (HSR) at baseline and endline. All but one domain (i.e. communication) of HSR were found to have positive significant difference between baseline and endline. Overall HSR improved significantly from 62.84% at baseline to 71.20% at end line (p<0.0001). In a multivariable logistic regression model, patients who were studied at the end line were four times more likely to have experienced positive responsiveness as compared to those at the baseline.
Forty-two (42) PPHFs were studied based on structural quality of maternal health services (MHS). The majority (71%) of the facilities were within 10 kilometers of participants’ residences. Of note, the majority (88.9%) of dispensaries and 60% of health centers were below the required staffing level. There were significant differences on structural quality of MHS between baseline and endline (2.38% and 30.9% respectively).
With respect to maternal health services utilization, 42 facilities were studied on nine maternal health service consumption indicators before and after the introduction of the DHFF initiative. There were significant differences in all indicators after DHFF introduction except those for intermittent presumptive treatment for malaria second dose, use of modern family planning methods, and mebendazole use.
Of 238 health care providers who participated in the Fidelity of Implementation (FoI) component of the study, the majority (76%) had adequate knowledge on the DHFF implementation issues while only 28% had high Fidelity of Implementation (FoI scores. For health service providers working in the rural settings, training and knowledge on the DHFF and Facility Financial Accounting and Reporting System (FFARS) were significantly associated with high FoI. In the multiple logistic regression model, both positive HSR (AOR 3.4 [95%CI: 1.637, 7.064]), and high maternal health service utilization (AOR 40.971[95%CI: 4.065, 412.927]) were strongly associated with high structural quality of MHS.
Health service providers indicated an improvement in both governance and accountability, especially in the areas of planning and budgeting, financial management and transparency, with the implementation of the DHFF. However, the majority of health care providers admitted to have not received adequate supportive supervision and mentorship. The providers also felt that this initiative added an additional burden to their routine work.
In general, the DHFF have affected the health system, specifically on health system performance in Tanzania. FoI was low despite training being offered to health care providers, which indicates a need for more investment on this aspect in order to have a resilient health system. Improved governance and accountability have been positive outcome on DHFF implementation, which indicate the merits in ongoing efforts to invest on governance and accountability at PPHFs.