Transcript The Mystery of Capital

Applying a Governance Lens to
Assess the Health Systems:
Maximising Access to Essential
Health Interventions.
A Focus on Tanzania
Masuma Mamdani, Ifakara Health Institute
Regional Summer School Governance for Health Systems
Development –Convened by SOAS, University of London in
association with IDS, University of Dar es Salaam, 18th-22nd July,
2011. Movenpick Hotel, Dar es Salaam
What is Governance?

Process of decision-making and how they are
implemented/ not implemented. Focuses on:
 formal and informal actors involved in
decision-making and implementing
 formal and informal structures that have been
set in place to arrive at and implement the
decision
Source: Wikipedia
2
What is Good Governance?

“….an ideal which is difficult to achieve in its
totality….to ensure sustainable human
development, actions must be take to work
towards this ideal with the aim of making it a
reality” UNESCAP

““….is important in ensuring effective health care
delivery, and that returns to investments in health
are low where governance issues are not
addressed.” Maureen Lewis, “Governance and Corruption in Public Health Care
Systems” CGD Working Paper 78, Jan 2006
3
What is a Health System?


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Complex, dynamic and ever changing.
not static
Many issues affect the ability of health systems to
deliver - governance, financing, HR, information,
access, quality, impacts of reforms in other areas
of the economies significantly, etc.
Many actors are involved – government,
ministries, CSOs, financing agents (global,
national), service providers, communities, etc
…their perspectives of the system vary.
4
Improving a health system has become a
balancing act…..
Decision makers:
 the need for disease specific programmes vs. those
targeting the health system as a whole;

national priorities with global initiatives;

policy directives with “street-level” realities
“the context”
5
Central question: efficient use of available
resources towards improved health
outcomes for ALL
Beyond the Health Sector
6
Central question: efficient use of available
resources towards effective access to
essential life saving health services for ALL
A Focus on the Health Sector
7
Tanzania’s total health sector budget
increased by 37% (nominal terms) from
2006/07 to 2007/08 (PER & MTEF, MoHSW)
Est. annual/capita
spending on health
(USD, nominal):
 6.8 - FY06
 10.3 - FY07
 13.8 - FY08
Est. health exp. of total
govt. exp.:
 9.7% FY06
 10.3% FY07
 10.5% FY08
Falling short of Abuja
target 15%
Excludes significant ‘off
budget funding’
8
Distortions……
“Aid [for HIV/AIDS] increased by three-quarters
and now finances 95% of Government plus donor
spending. The increase has been from off-budget
sources of finance, and only 19% of expected aid
in 2007/08 is included in the budget. HIV/AIDS is
now taking a staggering one-third of all aid to
Tanzania” (IMF ODA data, TACAIDS 2008).
Implications for national planning and budgeting?
Of establishing a clear link between strategic
plans, approved budgets and actual expenditures
against goals and targets?…GOVERNANCE?
How have and will GHIs shape the system
(HIV/AIDS, malaria, GAVI)?
9
Health Sector Reforms

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
Introduced in the 90s in response to worsening
situation
Financial sustainability is a key component of the
reforms
Cost Sharing:
 Generate Revenue
 Improve Quality of Care
 Enhance Equity
 Reduce frivolous consumption
10
Who pays for health care in Tz (2005/6
figures)?

Donor funding - grants/loans - direct or through
SWAp/ GBS, 45%

General tax revenue -28% - relatively progressive

Out-of-pocket payments (OOPs direct payments to
health care providers - 23% - very regressive

Health insurance contributions - less than 10% of
the population - mix
Government provides a basic package of public
preventive health services for ALL; minimal
financial protection for the most vulnerable
Source: SHIELD Project (IHI 2010), quoting Tanzania National Health Accounts 2005/06,
11
How many people are covered by HI in
Tanzania?

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9% in 2008 (SHIELD data)
13% in 2011 : NHIF (5.8%), CHF (6.6%), other
schemes (1%) (NHIF data)
Intention to increase HI coverage to 45% by 2015
Source: Borghi j and Joachim A. 2011. Who is covered by health insurance schemes and
which services are used in Tanzania? SHIELD Project. IHI, Tanzania.
SHIELD website: http://web.uct.ac.za/depts/heu/SHIELD/about/about.htm
12
HI coverage is highest among the better-off
working in the formal sector ….

In 2008, 12% of the richest groups were insured
compared to 4% of the poorest groups

Better off: mainly NHIF, some private and CHF

Poorest: all CHF
13
The poor pay a higher proportion of their
income than the rich.

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Contributions to the NHIF are the most progressive, but
only constitute a small amount of total funding (3%) &
benefit those who contribute (generally better off, small
proportion of the population).
Tax funding is the second most progressive source of
financing, benefits may be enjoyed by everyone (44%).
Out-of-pocket payments represent the largest component
of household contributions to health care financing, highly
regressive (53%)
Contributions to CHF are minimal (0%), regressive,
majority of members are poor, flat rate
IHI. 2010. Who Pays for Health Care in Tanzania. SHIELD Project HBS data 2000/01
14
But the rich benefit more than the poor……..

The poorest 20% receive less benefit than they
need.

Benefits from outpatient and inpatient care in
public hospitals, and private facilities are pro-rich.

Benefits from faith-based facilities are generally
evenly distributed
Source: IHI. 2010. Who benefits from health care. SHIELD Project).
15
The poor consume less health care, in spite of
greater need
Compared to poorest quintile, the top quintile are:
 3.4 times more likely to use modern contraception
 2.8 times more likely to have skilled attendance at delivery
 8.7 times more likely to have a C-Section
 7 times less likely to give birth at home AND have no
post-natal care
 40% more likely to have measles vaccination
 40% more likely to receive treatment for fever at a health
facility
 20% more likely to receive any ORS for diarrhoea
 14 times more likely to have slept under an ITN the
previous night
Source: Paul Smithson. 2006. Fair’s Fair. Health Inequalities and Health Equity in Tanzania. Prepared for
Women’s Dignity Project. IHI, Tanzania.
16
Barriers to effective access by the very poor

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Real costs of treatment (out of pocket):
 Drugs often greatest cost, than transport
 ‘Unofficial’ or ‘under-the-counter’ fees
Inflexible modes of payment
Ineffective exemption system for those too poor to
pay – exclusionary
Indirect costs (productive time lost)
 Often greater than direct costs
 Greater burden on women
Source: Mamdani M & Bangser M. 2004. Poor People’s Experiences of Health Services in Tanzania. A Literature
Review.
17
Ability and Willingness to Pay (WTP) –
some estimates

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~75% of respondents - “people’s ability to pay for health
services” has deteriorated during the last five years. (PSSS
2003)
~40% of respondents - know people who have been
refused treatment because of inability to pay; over ~25%
know “a lot of people”. (PSSS 2003)
Cost of treatment reason given by ~53% of respondents as
to why they did not seek care when they were last sick…
(PSSS)…even Tshs 500/- fee for consultation is beyond
the meager means of people, especially for women and
children (TzPPA 2003)
18
Ability ….. (cont)
30-40% of Lindi Rural District are classified as
“poor”. Food accounts for 70% of poor
households’. After minimum non-food
expenditure (school, health, taxes etc.), poor
households have only 1% of income flexible
= 1,600 Tshs per family per year.
Fee range is 200-500 Tshs, but community
willingness and ability to pay is low; nearly a third
of families reported that they had been unable to
pay for care in the most recent episode.
SC. 2005. The Unbearable Cost of Illness. Tanzania: SC.
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Ability …… (SC study continued)

Ability to pay is seasonal – better at harvest
time, decreases in dry season

For acute illness, 27% resorted to self
medication

For chronic illness, 54% reported taking no
action mainly because of lack of money.
20
What are the real costs of
treatment?
Evidence from TzPPA (2003):
Official fees can be 35% of the total costs [paid at
the facility level]; unofficial fees (hospital
referral, ANC card, syringe, gloves, ‘thank you
for staff’, drugs etc) can constitute 65% of the
total costs (based on available figures).
Informal ‘under the table’ payment from patients:
widespread across many countries and a heavy
burden to the poor (CGD 2006)
21
SC study(cont).…Most significant costs

Acute illness: Transport, laboratory tests
and drugs.

Chronic illness:Traditional healers,
transport and drugs.

Admission :
Food and accommodation
22
Coping Mechanisms
…and further impoverishment
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Delayed and inadequate treatment, or none at all
Sale of critical assets (their land, animals, crops, labour…)
Reduced food intake
Take children out of school
Child Labour
Borrow money
In the absence of safety nets….
23
Exemptions / Waivers (e/w)
Exemptions: cost-sharing should not apply to
children under five, MCH services (including
immunizations), TB, leprosy, paralysis,
typhoid, cancer, AIDS and epidemics.
Waivers: free services for the poorest of the poor.
24
Are exemptions/waivers effective?
“…a functional exemption and waiver system is
actually non-existent putting vulnerable and poor
people at risk by practically denying them access
to public health services.” Laterveer et al 2005
SC 2005:

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Lack of information and understanding about the e/w
among households and health workers.
Children under 5 – only 20% were exempted for
admissions; 49% for acute cases (at hospital level?)
Poor – only 50% were exempted from fees for acute illness
Better-off benefiting more than the poor on exemptions for
admissions (23% vs. 12%)
25
Some issues with e/w
What do e/w cover?
Who are the very poor? The vulnerable? Who
decides?
Are people aware of their rights?
What governance and accountability mechanisms
have been put in place?
What incentives do facilities have to grant e/w?
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Why should the poor benefit less? A “chain of
health deprivation”
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Perception of health status & need for care
(norms, beliefs, knowledge)
Propensity to seek (formal) care when ill
(knowledge of danger signs, expectations &
experience of health care)
Able to overcome barriers to access (distance, cost
(real and indirect), socio-cultural)
Actually receive quality care
Willing & able to comply with treatment
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The poor are…
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Less likely to perceive illness or “need” in the first
place
Less likely to seek treatment when ill
Less likely to use formal providers
More affected by cost barriers
More affected by distance barriers
Also affected by social barriers
Less likely to obtain quality care even if they
attend
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Challenges facing the health system
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Underskilled & de-motivated health staff
Weak management systems
Poor quality of care
Inadequate information to health consumers
Resource constrained
Growing burden…..(CDs + NCDs)
Poor access by the very poor to health care, etc
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HR - many needier and poorer Tanzanians are
underserved compared to the better off
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Highly uneven geographical HR distribution and
gap has been widening:
 In 2007/08: the best served region had twice the
number of health workers per 10,000 persons
than the worst served region
Areas chronically under funded and with lowest
staffing allocations have the highest rates of
poverty
 Per capita health staffing budget in 2008/9: Tshs
1,400 - Tshs 14,000 across LGAs
Source: GBS. 2008. Equity and Efficiency in Service Delivery: Human Resources. Background Analytical Note for the
Annual Review of GBS 2008, Tanzania.
30
Human Resource……
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An absolute shortage of skilled workers
Difficulties in attracting and retaining workers to
underseved areas + continued recruitment and transfers to
better served districts
High absenteeism
Poor productivity of existing staff
2007/08: MoHSW (Tz) recruited 3,645 workers, only 2,533
actually took up positions; 122 health workers were sent
to Rukwa but only 31 reported, leaving 8 facilities unoperational due to staff shortages
31
High absenteeism, low productivity, leakages
….chronic in developing countries
CGD 2006:
 Uganda
 only 56% of facility staff existed in district records
(ghost workers);
 average leakage rate for drugs in public rural facilities
was some 73%, ranging from 40-94%

Nigeria
 42% of staff had not been paid their salaries for 6
months in the past year;
 25% of health facilities had half the minimum pkg of
equipment; 40% had less than a quarter of what was
needed.
32
LGA: insufficient funding to deliver quality
health services…..
DxD : LGA responsible for delivery of quality
health services
 LG Budget: formula based recurrent block grants
({PE}, OC) + development budget
2008/9: development (28%), OC (14%), PE (58%)
 Council Plans (basis of planning - HMIS? delink of
planning and budgeting….)
 Teachers and health workers are the largest items of
expenditure in LG budgets: approx 50% of all
financial resources used at LG level

33
Public Expenditure Tracking….
……in Ghana leakage was 70% of total transfers; it was 40%
in Tanzania (results in inadequate funding for non-salary
spending and patients end up “contributing) (CGD 2006)
Role of complexity of parallel financing
mechanisms to the district, difficulties in
accessing resources and strategic
planning…….harmonisation & reform systems?
34
Health System Accountability in Tanzania

Health Facility Governing Committees (HFGCs)
introduced at all levels of the health system as a
mechanism for improving accountability between
health care providers and communities.
Responsible for:
 Community participation in health system
 Improving quality of care
 Ensuring effective exemptions
 Mobilising resources from communities (eg
CHF)
35
Rapid appraisal findings related to‘community
voice’ within HFGCs
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HFGCs largely reflect the interests of providers
rather than communities
HFGC needed local government approval and
support to access community members.
HFGC agenda had to be fitted into a broader
village meeting agenda.
Communities were generally wary of the HFGC
due to a broader distrust of government structures
and a distrust of providers which also extended to
the HFGC.
36
Towards strengthening the system ….(CGD
2006)

Better management: adequate incentives for health
professionals (supervision, enabling environment, PBF)

Improved logistics and information systems: drug
procurement reform, insitutional incentives e.g. hire and
fire staff; HR database - matching staff and wage
payments, eliminate abuses

Strengthened accountability: oversight and enforcement,
health provider audits, community oversight, patient
satisfaction surveys, citizens access to information on
resource flows and roles and responsibilities, citizen report
cards
37
Tanzania is committed….
Mkukuta (the National Strategy for Growth
and Poverty Reduction) seeks to:
“Improve quality of life and social wellbeing, with particular focus on the poorest
and most vulnerable groups”
and…“Reduce inequalities across
geographic, income, age, gender and other
groups”
38
But there are huge challenges…..
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Significant gains in child survival risk being undermined
by pervasive poverty, especially in rural areas:
 34% of households living below US$1/day (HBS 2007)
 Dependent on aid - about 40% of national budget in the
past few years
Disparities in child survival persist - between districts and
regions, urban vs rural, and by wealth status.
Those living in rural areas and those in poverty remain
disadvantaged both in terms of service uptake and
outcomes.
System -cope with continuing high burdens of
communicable diseases and growing NCDs
39
Key financing issues
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Commitment to gradually moving away from OOP
payments
Effectively identifying and protecting the
vulnerable
Potential of scaling up range of CBHIs…common
bond concept?
Promote cross-subsidies in overall health system:
 Improved tax funding levels
 Reduce fragmentation of risk pools
 Extension to non-formal sector from outset
Equitable allocation of tax (and donor) funds
according to need
40