Implementation  Research:  Taking  Results  Based  Financing  from  scheme  to  system  

 

Evolution  of  Results  Based  Financing  Policy  and  Programmes  in  Tanzania:  2006  to  2015  

 

 

October  2015  

 

 

 

 

       

 

 

 

 

 

 

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Acknowledgements  

We  gratefully  acknowledge  the  support  of  the  Tanzania  Ministry  of  Health  and  Social  Welfare  and  all  the  key  informants  during  the  course  of  this  study,  for  sharing  documents,  for  time  spent  during  the  interviews  and  for  their  concrete  and  detailed  feedback  to  earlier  drafts  of  this  research  report;  of  all  our  research  colleagues  from  the  10  Alliance  countries,  including  Maryam  Bigdeli  and  Zubin  Shroff  of  WHO  Alliance   for  Health  Policy  and  Systems  Research,   for   their   feedback  and   technical   insights  at  the   early   conceptual   and   preliminary   analysis   phase;   and   of   the   entire   technical   support   team   at  ITM,   in  particular  Por   Ir,  Matthieu  Antony  and  Bruno  Meessen  as  the  overall  coordinator,   for  their  ongoing   technical   support   and   leadership   of   the   overall   research.   We   also   wish   to   thank   Irene  Meshasi  and  Iddy  Mayumana  of  IHI  for  their  willingness  to  undertake  a  brief  rapid  assessment  visit  to  Shinyanga  at  a  very  short  notice;  and  to  Priscilla  Mlay  and  Humphrey  Mziray  of  IHI  for  their  very  valuable   administrative   and   financial   support   through   the   course   of   this   study.   Finally,   and  most  importantly,   we   wish   to   thank   WHO   Alliance   for   Health   Policy   and   Systems   Research   for  commissioning  and  funding  this  research.  

Research  Team  

Masuma  Mamdani  (PI)  Gemini  Mtei  (Co-­‐PI)  Catherine  Kahabuka  (Consultant  Researcher)  Jitihada  Baraka  (Research  Assistant)  Josephine  Borghi  (Technical  Advisor,  LSHTM)  Ottar  Maestad  (Technical  Advisor,  CMI)      

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Table  of  Contents  

Page  No.  

Acknowledgements…………………………………………………………………………….       2  

List  of  Tables  and  Figures  ……………………………………………………………………       4  

Acronyms…………………………………………………………………………………………..       4  

Executive  Summary……………………………………………………………………………       5  

1. Introduction………………………………………………………………………………..                              8  

1.1 Background……………………………………………………………………..       13  1.2 Objectives……………………………………………………………………….       13  

2 Methodology……………………………………………………………………………..       15  

2.1 Research  Design…………………………………………………………….       16  

2.2 Data/  Data  Collection…………………………………………………….       16  

2.3 Research  Tools……………………………………………………………….       17  

2.4 Data  Analysis……………………………………………………………………       18  

2.5 Quality  Assurance…………………………………………………………….       19  

3 Results:  analysis  of  the  results  based  financing  policy  timeline  ……       20  

3.1 The  national  context:  country  profile  and  health  systems….       21  

3.2 Chronological  analysis  of  RBF  policy  formulation  process….       29  

3.2.1 Phase  I:  political  momentum  for  MDGs  4  &  5,  2006–2015………   31  3.2.2 Phase  II:  building  national  consensus  for  P4P,  2007…     33  

3.2.3 Phase  III:  the  first  national  P4P  scheme,  2007-­‐2009…     36  

3.2.4 Phase  IV:  Pwani  P4P  pilot,  2010-­‐2013…         42  

3.2.5 Phase  V:  transitioning  from  P4P  to  RBF,    

             mid-­‐June  –  December  2013  ………………………………………     54  

3.2.6 Phase  VI:  the  national  RBF  design  and  early  scale  up  plans,    

           2015-­‐2015…………………………….             59  

4 Discussion………………………………………………………………………………         73  

5 Conclusion  and  Recommendations………………………………………..         79  

6 References  ……………………………………………………………           82  

7 Annexes  Annex  A:     List  of  Key  Informant  Interviewees    Annex  B:     Kishapu  Summary  Field  Report,  May  2015.  Annex  C:     Guiding  questions  for  key  informant  interviews  (central  level)  Annex  D:     Guiding  questions  for  pilot  district    Anned  E:     Informed  Consent  Form  Annex  F:   Scaling  Up:  Matrix  of  key  events  from  end  2006  to  May  2015  Annex  G:     Tanzania  Policy  Timeline  

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List  of  Tables    

Table  1.  Data  sources  

Table  2.  Economic  and  health  status  indicators  for  Mainland  Tanzania  

Table  3.  Health  financing  indicators  for  Mainland  Tanzania    

Table  4.  Health  service  coverage  indicators  for  Mainland  Tanzania  

Table  5.  Influence  and  position  of  key  actors  during  Phase  I  and  II    

Table  6.  Phase  I  and  II  –  facilitators  and  barriers  

Table  7.  Influence  and  position  of  key  actors  during  Phase  III  

Table  8.  Phase  III  –  facilitators  and  barriers  

Table  9.  Influence  and  position  of  key  actors  during  Phase  IV    

Table  10.  Phase  IV  –  facilitators  and  barriers  

Table  11.  P4P  pilot  evaluation  –  summary  findings  

Table  12.  Phase  V  –  facilitators  and  barriers  

Table  13:  Key  design  features  –Pwani  P4P  pilot,  national  RBF  programme  

Table  14.  An  update  on  Kishapu  district  pre-­‐Pilot  (August  2015).  

Table  15.  Shifting  Influence  and  position  of  key  actors  from  Phase  I  to  Phase  VI    

Table  16.  Phase  VI  –  facilitators  and  barriers  

 

 

List  of  Figures    

Figure  1.  Road  to  Tanzania’s  Vision  2025  

Figure  2.  Timeline:  RBF  policy  formulation  process,  Nov  2006-­‐Sept  2015  

Figure  3.  RBF  phasing  and  implementation  timeline    

Figure  4.  RBF  invoicing  and  payments  

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Acronyms    AHPSR     Alliance  for  Health  Policy  and  Systems  AIDS     Acquired  Immune  Deficiency  Syndrome  ANC     Ante  Natal  Care  BEMOC   Basic  Emergency  Obstetric  Care  BRN     Big  Results  Now  CBHI     Community  Based  Health  Insurance  CCHP     Council  Comprehensive  Health  Plan  CHAI     Clinton  Health  Access  Initiative  CHF     Community  Health  Fund  CHMT     Council  Health  Management  Team  CHSB     Council  Health  Service  Board  CHW     Community  Health  Worker  CMI     Chr.  Michelsen  Institute  COIA     Commission   for   Information  and  Accountability   for  Women’s  and  Children’s       Health  CORDAID   Catholic  Organisation  for  Relief  and  Development  Aid  CSO     Civil  Society  Organisation  DANIDA   Danish  International  Development  Agency  DHIS     District  Health  Information  System  DHS     Demographic  and  Health  Surveys  DMO     District  Medical  Officer  DP     Development  Partners  DPG     Development  Partners  Group  FB     Faith  Based  FBO     Faith  Based  Organisation  GDP     Gross  Development  Product  GFF     Global  Financing  Facility  GIZ     German  Agency  for  International  Cooperation  GoN     Government  of  Norway  GoT     Government  of  Tanzania  HBF     Health  Basket  Funder  HBS     Household  Budget  Survey  HF     Health  Financing  HFGC     Health  Facility  Governing  Committee  HFS     Health  Financing  Strategy  HIV     Human  Immunodeficiency  Virus  HMIS     Health  Management  Information  System  HRH     Human  Resource  for  Health  HRITF     Health  Results  Innovation  Trust  Fund  HSSP     Health  Sector  Strategic  Plan  IAG     Internal  Auditor  General  IDI     In-­‐depth  Interview  IHI     Ifakara  Health  Institute    IPT2     Intermittent  Preventive  Treatment,  second  dose  ITN     Insecticide  Treated  Net  ISC     Interministerial  Steering  Committee  JAHSR     Joint  Annual  Health  Sector  Review  

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KI     Key  Informant  KII     Key  Informant  Interview  LGA     Local  Government  Authority  LMICs     Low  and  Middle  Income  Countries  LSHTM     London  School  of  Hygiene  and  Tropical  Medicine  MDG     Millennium  Development  Goal  MKUKUTA   Mkakati  wa  Kukuza  Uchumi  na  Kupunguza  Umaskini  Tanzania    MNCH     Maternal,  Neonatal  and  Child  Health  MNH     Maternal  and  Newborn  Health  MoFEA     Ministry  of  Finance  and  Economic  Affairs  MoHSW   Ministry  of  Health  and  Social  Welfare  MoU     Memorandum  of  Understanding  MSD     Medical  Stores  Department  MTR     Midterm  Review  NBS     National  Bureau  of  Statistics  NGO     Non  Governmental  Organization  NHA     National  Health  Account  NHIF     National  Health  Insurance  Fund      NIMR     National  Institute  of  Medical  Research  Norad     Norwegian  Agency  for  Development  Cooperation  NSGRP     National  Strategy  for  Growth  and  Reduction  of  Poverty  NSSF     National  Social  Security  Fund  NTPI     Norway  Tanzania  Partnership  Initiative  NVC     National  Verification  Committee  OC     Other  Charges  P4H     Providing  for  Health  P4P     Pay  for  Performance  PBF     Performance  Based  Financing  PER     Public  Expenditure  Review  PHC     Primary  Health  Care  PHI     Private  Health  Insurance  PHSDP     Primary  Health  Services  Development  Programme  PMO-­‐  RALG   Prime  Minister’s  Office,  Regional  Authorities  and  Local  Government  PMT     Pilot  Management  Team  RAS     Regional  Administrative  Secretary  RBF       Results  Based  Financing  RCC     Regional  Certification  Committee    RCH     Reproductive  and  Child  Health  RHMT     Regional  Health  Management  Team    RNE     Royal  Norwegian  Embassy  RNMCH   Reproductive,  Neonatal,  Maternal  and  Child  Health  SDC     Swiss  Development  Corporation  SHIB     Social  Health  Insurance  Benefit  SP     Sulphadoxine  Pyrimethamine  SSRA     Social  Security  Regulatory  Authority  TDV     Tanzanian  Development  Vision  THE     Total  Health  Expenditure  TIKA     Tika  kwa  Kadi  

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TPMNCH   Tanzania  Partnership  for  Maternal,  Neonatal  and  Child  Health  TWG     Technical  Working  Group  UHC     Universal  Health  Coverage  UNDP     United  Nations  Development  Programme  UNFPA     United  Nations  Family  Planning  Association  UNICEF   United  Nations  Children’s  Fund  URT     United  Republic  of  Tanzania  USAID     United  States  Agency  for  International  Development  USG     United  States  Government  vb/co     Verbal  Communication  WB     World  Bank  WHO     World  Health  Organisation        

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Executive  Summary    

Background  

Results   Based   Financing   (RBF)   has   a   long   history   of   implementation   in   high   income  countries.  The  intervention  has  been  gaining  momentum  in  the  health  sector  in  sub-­‐Saharan  Africa.   However,   the   current   evidence   on   effectiveness   in   low   income   settings   is   sparse.    Also,   limited  attention  has  been  paid  to  context-­‐specific  factors  that  may  enable  or  hinder  the  RBF  implementation  process  and  its  overall  effectiveness.  An  evaluation  of  the  pilot  RBF  scheme   intending   to   motivate   health   workers   towards   enhancing   service   coverage   and  providing   better   quality   of   Reproductive   and   Child   Health   (RCH)   care   in   Pwani   region   of  Tanzania  found  limited  positive  effects  on  targeted  RCH  services;  as  well  as  several  design  and  implementation  challenges  with  respect  to  scaling  up  the  intervention.  The  Pwani  pilot  has  been  redesigned  and  transformed  into  a  Results-­‐Based  Financing  initiative  that  aims  to  improve   service   use   and   equity,   as   well   as   the   quality   and   efficiency   of   care.   The   RBF  scheme  is  currently  in  a  pre-­‐pilot  phase  in  one  district.  By  2019,  the  Scheme  is  expected  to  be   rolled-­‐out   to   at   least   seven   regions   with   relatively   poor   health   outcomes   and   high  poverty  levels.    This  research  seeks  to:    document  and  analyse  the  evolution  of  RBF  policy,  concepts  and  approaches  in  Tanzania  from  since  December  2006  to  early  scaling-­‐up  plans  in  September   2015;   and   identify   enablers   and   barriers   to   scaling-­‐up.   Specifically,   it   aims   to  explain  why  the  policy  process  unfolded  the  way  it  did  to  understand  the  decision  to  scale  up   and   identify   how  each   step  of   the  policy   process   has   contributed   to   strengthening  or  weakening   national   ownership   to   RBF.   This   research   is   part   of   a   multi-­‐country   research  initiative  supported  by  the  Alliance  for  Heath  Policy  and  Systems  Research  (AHPSR).  Findings  will   be  widely   circulated   and  will   lend   to   a   better   understanding   of   the   RBF   landscape   in  Tanzania,  and  provide  useful  insights  to  emerging  implementation  challenges.  Lessons  from  cross-­‐country  comparisons  will  provide  deeper  insights  for  further  scaling  up  and  sustaining  such  initiatives,  nationally  and  internationally.  

Methodology  

The  research  was   informed  by  four  sources  of  data:  document  review;  direct  observations  of  technical  meetings  and  workshops  to  assess  progress  in  the  evolution  of  RBF  policy  and  implementation  process;   26   in-­‐depth   interviews  with   a   cross   section  of   key  national   level  informants  involved  in  the  RBF  dialogue  process,  using  a  semi-­‐structured  questionnaire;  and  nine  semi-­‐structured   informal  discussions  with  key   informants   in   the  pilot  district,  using  a  standard   list   of   guiding   questions.   Interviews  were   conducted   by   four   senior   researchers  trained  in  qualitative  research  methods  and  one  junior  social  scientist,  closely  managed  and  overseen   by   the   Principal   Investigator.   Data   were   triangulated   across   respondent   groups  and  backed  by  supporting  documentary  evidence.  Ethical  approval  was  obtained  from  the  Institutional  Review  Board  of   the   Ifakara  Health   Institute,  as  well  as   from  the  WHO  Ethics  Review   Committee.   Verbal   informed   consent   was   obtained   from   all   respondents.   The  information  was  anonymised  and  confidential.  We  developed  a  timeline  to  situate  key  steps  towards  the  RBF  scale  up,  and  report  on  the  multi-­‐dimensional  evolution  of  the  RBF  policy  along  three  broad  key  dimensions:    geographical  coverage,  service  coverage  and  integration  with   the  health   system.  We  drew  on   the  health  policy   triangle   to   interpret  our  data;   and  used   stakeholder   analysis   tools   to   analyze   the   power   of   actors,   their   networking   and  political  will  or  position  towards  the  RBF  initiative  in  order  to  clearly  recognize  whether  they  are  enablers  or  hinderers  of  the  scaling  up  process.    

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Key  Findings  

The  National   context:   Tanzania’s   health   system   is   stretched:   financing   is   fragmented   and  reliant  on  external   support,  with  significant  out-­‐of-­‐pocket  payments;  worker  motivation   is  low   coupled   with   severe   shortages   of   staff,   medicines   and   supplies;   and   health   facilities  receive   inadequate   funds   with   limited   financial   autonomy.   Achieving   Universal   Health  Coverage   has   been   a   key   priority   since   independence   and   further   stipulated   in   several  policies   and   strategies.   However,   the  maternal  mortality   ratio   remains   unacceptably   high  with  many  poor  rural  women  and  children  severely  constrained  in  accessing  quality  health  care.   Attention   is   focused   on   strengthening   delivery   of   quality   primary   health   services   to  optimize  use  of  available  scarce  resources  (a  shift  from  input  to  output  based  financing)  as  well  as  to  ensure  equitable  access  to  essential  care.  The  Government  has  recently  embarked  on  two  major   initiatives:  the  Big  Results  Now  in  Health  (BRN)  and  Results-­‐based  Financing  (RBF).   The   BRN   initiative   aims   to   facilitate   the   achievement   of   Tanzania’s   Development  Vision  2025  and  reduce  maternal  and  neonatal  mortality   through   improving  performance,  governance   and   accountability   in   primary   health   care   (PHC).   The   RBF   initiative   strives   to  improve   provider   accountability   for   results   and   encompasses   broader   health   system  strengthening  measures.    Both  the  BRN  and  RBF   initiatives  are  embedded   in  the  medium-­‐term  Health  Sector  Strategic  Plan  (HSSP)   IV  that  will  guide  the  health  sector   from  2015  to  2020  (The  World  Bank  March  2015).    

There   has   been   a   phased   evolution   of   the   RBF   policy   process   from   2006   onwards,   with  different  actors  trying  to  promote  the  RBF  agenda  onto  the  national  level.    

Phase  1   (from  2005  onwards):   the  build  up  of  a  high   level   global,   regional  and  national  political  momentum  and  partnerships  to  address  MDGs  4  &  5,  with  President  Kikwete  of  Tanzania   and   the   Norwegian   prime   minister   at   the   forefront.   They   wanted   to   make   a  political  commitment  to  maternal  and  neonatal  health  and  get  it  translated  into  action.  This  resulted   in   the   2006  Norway-­‐Tanzania   Partnership   Initiative   (NTPI)   to   support   Tanzania’s  efforts   to   reduce   child  and  maternal  mortality  within  a  performance   incentive   framework  which  the  President  was  keen  to  introduce,  following  early  success  stories  from  Rwanda  and  Haiti.  The  NTPI  had  four  separate  components:  general  support  to  the  Health  Basket  Fund,  support   to   the   Health  Management   Information   System,   Pay   for   Performance   (P4P)   and  support  to  Non  Governmental  Organisations  (NGO).  

Phase   II   (2007)-­‐  Norway   tried   to   open   up   the   P4P   process   in   Tanzania   towards   a  broad  based  involvement  of  key  national  stakeholders,  with  support  from  Ifakara  Health  Institute  (IHI)   and   Broad   Branch   Associates   (BBA).   Health   development   partners   were   generally  reluctant   to   support   the   process   for   several   reasons,   including:   concerns   regarding   the  capacity   of   the   health   system   to   handle   such   a   major   reform;   suspicion   surrounding  Norway’s   ulterior   motives   in   bypassing   health   development   partners   and   wanting   to   re-­‐enter  a   sector   that   they  had   just   recently  exited   from  and   further  wanting   to   introduce  a  performance  based  health  system;  and  lack  of  adequate  evidence  on  P4Ps  effectiveness  in  low  income  settings.  Norway  tried  to  reach  a  compromise  to  channel  the  P4P  funds  through  the   Basket   provided  Health   Basket   Fund   (HBF)   partners   agreed   to   a   jointly   endorsed   P4P  system,  but  this  did  not  happen:  HBF  partners  did  not  agree.  

Phase  III  (2007-­‐2009)  -­‐  Norway  supports  the  MoHSW  towards  the  development  of  the  first  national  pay  for  performance  scheme:  the  design  process  was  initially  led  by  IHI  on  behalf  of  MoHSW,  and  with  MoHSW  engagement.   It  was   subsequently   revised  by  MoHSW,  with  significant  government  ownership  to  the  revised  version.  Health  basket   fund  partners  had  

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several  concerns  with  the  final  MoHSW  design,  mainly  linked  to  the  choice  of  indicators  and  a  weak  verification  system.  Eventually,  all  health  development  partners  -­‐  health  basket  fund  partners,   the  USAID  and  Norway  –  reached  a  consensus  that  the  design  should  be  piloted  first.   Based   on   a   principle   of   no   Pilots,   the   MoHSW   disagreed   and   proceeded   to   go  nationwide.  There  was  commitment  to   institutionalize.  The  P4P  concept  had  already  been  incorporated  in  the  third  Health  Sector  Strategic  Plan.  District  councils  had  been  instructed  to  include  an  RBF  budget  line  in  their  Comprehensive  Council  Health  Plan.  The  first  national  P4P  scheme  was  unsuccessfully  implemented  for  a  number  of  reasons,  including  challenges  with   the  design;   limited  understanding  of   the   concept   at   all   levels   of   the   system  with   no  prior  preparations;  and   inadequate  technical,   implementation  and  financial  arrangements.  There   followed   strained   relations,   among   the   development   partners,   as   well   as   between  development  partners  and  the  Government  of  Tanzania  whose  authority  and  interests  had  been  undermined.    

Phase   IV   (2010-­‐2013)-­‐  CHAI   (Clinton  Health  Access   Initiative)   supported   implementation  of  Pwani  P4P  Pilot:   the  Norwegian  Embassy   in  Dar  es  Salaam  and   the  Tanzanian  MoHSW  were   under   immense   pressure   to   effect   the   time   bound   partnership   agreement   (NTPI)  which  had  to  be  performance  based.  In  early  2011,  the  MoHSW  rushed  into  implementing  a  revised  P4P  model  in  the  Pwani  region  with  the  aim  of  informing  the  national  model  and  to  generate  evidence  on  its  impact.  The  Pilot  was  funded  as  a  bilateral  project  from  outside  the  Basket.  CHAI  was  contracted  to  support  the  government  –  lead  the  design  and  manage  the  implementation  process.     Ifakara  Health   Institute   (IHI)  was   commissioned   to   carry   out   an  independent   impact,   process   and   economic   evaluation   of   the   Pilot   (undertaken   in  collaboration  with   the  London  School  of  Hygiene  and  Tropical  Medicine   (LSHTM)  and  Chr.  Michelsen   Institute   (CMI)   in   Norway).   The   USAID   contracted   Broad   Branch   Associates   to  support   the   design   process.   The   MoHSW   had   technical   authority   to   approve   design  elements   and   implementation   arrangements.   A   joint   Pilot   Management   Team   (PMT)  comprised   of   CHAI   and   MoHSW   staff   led   the   Pwani   P4P   pilot.   However,   without  independent  financial  sources  to  deploy  unilaterally,  the  MoHSW  was  completely  reliant  on  the  Government  of  Norway  (GON)  and  CHAI  to  execute   its  program.  Although  an  advisory  committee  which   incorporated   other   development   partners   and   elements   of   civil   society  was   set   up   to   review   and   advise   the   pilot   management   team   on   a   quarterly   basis,   all  decision   making   powers   resided   with   the   steering   committee   composed   only   of  representatives  from  the  MoHSW,  Norwegian  Embassy  and  CHAI.  With  limited  authority  in  the   use   of   CHAI’s   management   and   implementation   funds,   and   therefore   the  implementation  process,  the  Pwani  Pilot  was   largely  viewed  by  development  partners  and  national  stakeholders  to  be  a  donor  driven  and  a  donor  dependent  process  without  much  national  ownership.  In  early  2013,  following  a  national  P4P  stakeholder  meeting  to  discuss  best  practice  P4P  models  within  the  Region,  the  MoHSW  additionally  created  a  Task  Force  to  oversee  the  transition  from  the  Pilot  to  the  new  design  for  the  RBF  programme.  Not  as  broadly   based   as   the   P4P   Advisory   Committee   but   with   the   addition   of   prospective  development  partner  donors,  the  Task  Force  was  intended  to  attract  health  basket  partners  to  support  the  scale  up  process,  and  make  sure  that  P4P  does  not  remain  viewed  as  a  stand  alone  bilateral  project,  but  as  a  system  strengthening  initiative.  

Phase  V  (mid-­‐June  to  Dec  2013)  -­‐  transitioning  from  pay  for  performance  to  results  based  financing   led   by   the   World   Bank:   Norway   who   did   not   have   the   capacity   to   support   a  national   scale   up   process   and   was   once   again   moving   out   of   Tanzania’s   health   sector,  suggested   to   the  World   Bank   to   take   on   responsibility   for   supporting   the  Government   of  

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Tanzania  in  the  scaling  up  phase,  using  the  World  Bank  managed  Health  Results  Innovation  Trust  Fund  which  Norway  had  established  and  was  being  supported  by  Norway  and  the  UK  since   2007   and   2009,   respectively.   The   Bank   emerged   as   a   key   RBF   player,   with   USAID  continuing   to   lend   their   support   via   Broad   Branch   Associates.   Subsequently,   the   Bank  supported  a  national  RBF  forum  that  resulted  in  a  conceptual  shift  from  project  based  P4P  to   a   national   RBF   system,   raising   awareness,   garnering   ideas   and   generating   increasing  support   from   across   a   wide   cross   section   of   stakeholders   towards   a   redesign   of   an   RBF  system  strengthening  model   for  Tanzania  –  one  that  would  be  transitional  and   integral   to  the  Health  Financing  Strategy  that  was  unfolding  around  the  same  time.  A  multistakeholder  national  RBF  assessment  team  to  provide  recommendations  for  a  national  programme  was  put  in  place,  with  the  Bank  keen  for  a  maximum  buy  in  at  the  outset.  The  Pwani  P4P  impact  evaluation  results  were  disseminated  in  December  2013:  results  were  regarded  by  some  as  inconclusive.  Scaling  up  decisions  were  political,  yet  evidence  informed  drawing  on  positive  lessons  from  Pwani,  the  CORDAID  experience,  and  elsewhere  from  neighbouring  regions.    

Phase  VI  (2014  to  Sept  2015)  –  towards  finalizing  the  RBF  national  design  and  early  scale  up  plans:  backed  by   the  most  powerful   institution   in   the  World,   the  World  Bank’s   senior  health  adviser,  noted  by  the  RBF  coordinator  and  several  others  as  Tanzania’s  RBF  national  champion,   is   very   strategically   positioned   to   support   and   guide   all   RBF   key   stakeholders  towards  a  common  agenda.  The  redesign  process  has  been  very  much  driven  by  the  World  Bank.  The  RBF  coordinator  has  been  actively  involved  in  the  RBF  design  formulation  process  and  the  SWAp  Health  Financing  Technical  Working  Group  making  RBF  a  prominent  agenda  item  in  its  meetings.  Bilateral  health  development  partners  have  been  largely  excluded  from  the  decision-­‐making  processes  till  very  recently.  

Tentative  plans  and  funds  for  phasing  the  RBF  initiative  to  seven  regions  over  the  next  five  years   are   in   place.   The   rollout   is   harmonized  with   the   Big   Results  Now   (BRN)   Star   Rating  Assessment   that   is  also  used  to  determine  health   facility   readiness   for  RBF.    The  RBF  pre-­‐pilot   is   under   way   in   one   district   of   Shinyanga   Region,   identifying   early   implementation  challenges,   including   equity   concerns   and   systemic   constraints   affecting   most   enrolled  facilities   resulting   in   their   low  performance   scores   and   subsequent  motivational   earnings.  The   scale   up   process   will   need   to   be   very   context   specific   and   adapt   to   the   diversity,  available  operational  capacity,  and  technical  and  financial  resources.  Present  support  to  the  national   RBF   initiative   amounts   to  USD  106  million   that   includes   funding   from   IDA  Credit  ($30M),  Power  of  Nutrition  ($10M),  Global  Financing  Facility  ($20M)  and  $46M  from  USAID  that  will  be  administered  through  a  single  donor  trust  fund  administered  by  the  World  Bank.    

Overall,   there   is   a   more   supportive   RBF   landscape   with   key   actors,   initiatives   and   plans  aligned.   The   impact   evaluation   research   consortium   (IHI,   LSHTM,   CMI)   is   equally   keen   to  addresses  the  most  relevant  policy  questions,  as  prioritized  by  MoHSW  (and  the  Bank).  The  World  Bank’s  flagship  Basic  Health  Service  Programme  has  also  evolved  into  a  Program  For  Results  –Strengthening  Primary  Health  care  for  Results  Programme  that  supports  both  the  RBF   and   health   basket   fund.   A   performance   based   Health   Basket   Fund  Memorandum   of  Understanding   with   the   Government   is   in   place;   and   aligned   to,   and   supportive   of,   the  achievement   of   the   Fourth   Health   Sector   Strategic   Plan   and   the   Big   Results   Now   (BRN)  initiative.  The  National  Health  Financing  Strategy  which  the  government  is  in  the  process  of  finalising,  incorporates  the  RBF  strategy.    

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The   trajectory   of   the   RBF   initiative   is   closely   and   clearly   linked   to   the   evolving   policy  environment,  nationally  and  amongst  development  partner  recipient  countries.      There  is  a  growing  interest  among  bilaterals  in  results-­‐based  aid  to  improve  accountability  and  return  on   aid   investment.   The   evolving   national   policy   environment   is   also   expected   to   have   an  effect   on   the   evolution   of   RBF   thinking.   The   Big   Results   Now   initiative   signals   a   call   for  faster,   demonstrable   impact   as   well   as   greater   accountability   (by   civil   service,   including  health)  to  the  Office  of  the  President.    

There  is  a  real  need  for  an  honest  policy  discussion  and  constructive  dialogue  amongst  key  national  stake  holders  and  Tanzania’s  development  partners  on  the  real  future  direction  of  Tanzania’s   health   system,   and   the   level   of   commitment   required   to   make   it   happen.  Discussions  need  to  be  open  and  inclusive  and  include  a  wider  group  of  stakeholders.    RBF  is  very   intense   and   operationalisation   of   RBF   remains   a   huge   challenge,   as   evidenced   by  lessons   from   the  Pwani   pilot   as  well   as   from   the  on-­‐going  Kishapu  pre-­‐   pilot.   There   exist  several   concerns   revolving  around  existing  design,   foremost  being   those   related   to  health  management   information   system,   data   quality,   a   feasible   verification   system   and   timely  payments,  health  system  issues  and  its  long-­‐term  sustainability.  Across  board,  the  dominant  concern  amongst  many  of  the   interviewed  stakeholders   is  the  continuity   in  resources  that  will  be  required  for  implementing  and  sustaining  the  RBF  strategy  on  a  severely  constrained  health  system:  financial,  technical,  and  managerial.  Such  a  huge  reform  needs  to  be  clearly  though   through;   it   needs   to   be   owned   by   the   Government   with   the   required   resources  integrated  into  the  national  budget.    

The   nature   of   the   RBF   policy/programme   is   also   likely   to   CHANGE   -­‐   as   the   range   of  interested  actors  broadens.  

An   important   recommendation   from   interviewed   stakeholders   towards   promoting   better  working   relationship   between   key   stakeholders,  was   to   agree   on   a   framework   of  mutual  accountability  between  the  Government  of  Tanzania  and  her  development  partners.  

Some  key  recommendations  from  interviewed  stakeholders  towards  making  an  RBF  system  work,  include:  

• Reform   of   public   sector   financial   management   procedures   to   facilitate   quick  disbursements  of  flexible  funds  to  facilities  according  to  need,  and  building  central  level  capacity  and  leadership  to  make  this  possible.  

• Strengthening  implementation  capacity  at  regional  and  district  level  with  firm  roles  and  responsibilities  to  make  an  indicator  system  work  at  the  facility  level.  

• Institutionalise   RBF   as   part   of   routine   funding   of   the   sector   possibly   through  implementing   a   minimum   benefits   package   which   includes   many   of   the   currently  incentivized  services    

• Strengthen  the  routine  information  system,  address  supply  side  issues  and  put  in  place  effective   accountability   mechanisms   and   feedback   structures   to   facilitate   flow   of  information  and  promote  participation  of  key  health  system  stakeholders.  

• Research   for   a   better   understanding   of   the   nature   of   incentives   that   will   motivate  everyone   in  a  given  context;   to   learn  how   (and   if)   the  RBF   initiative  adapts   to   specific  contexts   and   needs;   and   its   potential   for   system   strengthening   as   well   as   improved  coverage  of  essential  health  care  towards  better  health  outcomes.    

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1. Introduction  

1.1 Background  

Results   Based   Financing   (RBF)   has   had   a   long   history   of   implementation   in   high   income  countries,  with  the  evidence  pointing  to  significant   improvements   in   incentivised  practices  (Kane   2007,   Casalino  &   Ester   2007).   RBF   has   also   been   gaining  momentum   in   the   health  sector  in  low  and  middle-­‐income  (LMIC)  countries,  in  particular  in  sub-­‐Saharan  Africa,  where  it   has   been  widely   regarded   as   a   promising   strategy   to   increase   coverage   and   quality   of  maternal  and  child  health  services  and  make  progress  towards  the  Millennium  Development  Goals   (MDGs)   4   and   5   (Martinez   et   al   2012).   And  more   recently,   as   a  means   to   improve  system  performance  (Ireland  et  al  2011)  and  help  systems  move  towards  Universal  Health  Coverage   (UHC).1   RBF   is   not   simply   a   health   sector   performance   tool,   but   something  increasingly  being  considered  by  some  donors  as  a  new  aid  modality,  to  improve  impact  of  development  assistance  (Grittner  2013).    

RBF   in   the   health   sector   has   been   defined   as   "a   cash   payment   or   non-­‐monetary   transfer  made  to  a  national  or  sub-­‐national  government,  manager,  provider,  payer  or  consumer  of  health   services   after   predefined   results   have   been   attained   and   verified.   Payment   is  conditional  on  measurable  actions  being  undertaken."2    RBF  is  an  umbrella  term  with  many  different  terms  being  used  interchangeably  for  essentially  describing  the  same  concept;  and  at  times  linked  to  different  incentives  and  payment  arrangements  (Musgrove  2011).   It  can  operate  on  the  demand-­‐side,  incentivising  health  service  uptake  by  patients,  or  the  supply-­‐side,   to   promote   health   system   performance   and   accountability   or   both   (Meessen   et   al  2011).   In   2013   thirty-­‐one   low-­‐   and   middle-­‐income   countries   were   implementing   RBF  programmes,  supported  by  $1.6  billion  in  low-­‐interest  loans  from  the  World  Bank  and  $404  million  from  the  Health  Results  Innovation  Trust  Fund  (HRITF)3,  which  was  co-­‐funded  by  the  governments   of   Norway   and   the   United   Kingdom.   About   75%   of   HRITF   funding   supports  programs   in   sub-­‐Saharan  Africa,  mainly   targeting  maternal   and   child  health   services.   (The  World  Bank  2013).    

Despite   the  widespread   implementation  of  RBF  programmes  across   the  African  continent,  the  evidence  base  on  RBF  effects  in  low  income  settings  is  very  limited  (Eichler  et  al  2013,  Grittner  2013,  Hasnain  et  al  2012,  Witter  et  al  2012,  Morgan  et  al  2013,  Toonen  et  al  2009).    To  date,  there  have  been  very  few  rigorous  evaluation  studies  in  Africa  (Basinga  et  al  2011,  Binyaruka   et   al   2015,   Bonfrer,   Soeters   et   al   2014,   Bonfrer,   Van   de   Poel  &   Van  Doorslaer    2014).  There  has  also  been  limited  assessment  in  low  income  settings  of  RBF  effects  on  user  costs  (Soeters  et  al  2011),  patient  satisfaction  and/or  quality  of  care  (Huntington  et  al  2010,  Witter   et   al   2012),   equity   (Priedeman   Skiles   et   al   2012)   and   health   outcomes.   Limited  attention   has   been   paid   to   context-­‐specific   factors   that   may   enable   or   hinder   the   RBF  implementation  process  and  its  overall  effectiveness  (Olafsdottir  et  al  2014).    

Results  based  financing  in  Tanzania  

Tanzania’s  RBF  history  dates  back  to  2006  when  CORDAID  (Catholic  Organisation  for  Relief  and   Development   Aid),   a   non   governmental   organization   (NGO)   from   the   Netherlands,                                                                                                                            1  http://www.rbfhealth.org/rbfhealth  2  See  footnote  (1)  3  http://www.worldbank.org/en/news/press-­‐release/2013/12/11/world-­‐bank-­‐global-­‐fund-­‐results-­‐based-­‐financing-­‐maternal-­‐child-­‐health.    

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introduced   performance-­‐based   financing   (PBF)   in   five   rural   areas   in   Tanzania   (Canavan  &  Swai,   2008;   Cordaid   2008;   Van   de   Looij,   Oct   2009].4   CORDAID   altered   their   historic,  unconditional   subsidy   to  mission  health   facilities  and   introduced  PBF   to  get  better   results  for  their  subsidy.  Around  the  same  time,  following  discussions  between  the  Governments  of  Norway  and  Tanzania   in   late  2006,   there  ensued  a  growing   interest   in   introducing  an  RBF  scheme  on  a  nation-­‐wide  basis.5    

Starting   January   2011   and   with   financial   support   from   the   Norwegian   government,  Tanzania’s   Ministry   of   Health   and   Social   Welfare   (MoHSW)   introduced   a   Pay   for  Performance  (P4P)  pilot  in  seven  districts  of  the  Pwani  region  of  Tanzania.  The  Pwani  pilot  was  designed  to  motivate  health  workers  towards  increasing  coverage  and  providing  better  quality   of   Reproductive   and   Child   Health   (RCH)   care.   It   intended   to   test   and   inform   the  design  of  a  sustainable  P4P  approach  for  national  scale-­‐up.    A  process,  impact  and  economic  evaluation  of  the  P4P  Pilot  commissioned  by  Norway,  was  carried  out  by  the  Ifakara  Health  Institute6  over  a  29-­‐month  period  from  August  2011  to  December  2013  (Borghi  et  al  2013).  The   evaluation   findings,   which   were   disseminated   in   December   2013,   reported   limited  positive  effects  on  targeted  services  coupled  with  a  reduction  in  coverage  of  non-­‐targeted  services   in  dispensaries  and  several  design  and   implementation  challenges   including  some  emerging   concerns   with   respect   to   the   scale   up.7   In   2013,   the  Mid   Term   Review   of   the  Tanzania’s   third   Health   Sector   Strategic   Plan   (HSSP   III),   recommended   instituting  performance  management  systems  in  part  through  a  national  Pay  for  Performance  strategy  (MoHSW  2013).  

The  Pwani  P4P  pilot  has  been   redesigned  and   transformed   into  a  Results-­‐Based  Financing  initiative   in   conjunction   with   seeking   out   new   funding   partners   and   implementation  arrangements.  The  RBF  scheme  aims  to  improve  service  use  and  equity  in  use,  as  well  as  the  quality  and  efficiency  of  care  –  especially  among  primary  care  facilities,  the  productivity  of  service  delivery,  accountability  and  responsiveness,  as  well  as   the  use  of  data   for  decision  making  (MoHSW  undated,  August  2015).  The  RBF  scheme  is  currently  in  a  pre-­‐pilot  phase  in  Kishapu  district  in  Shinyanga  region.  Starting  beginning  of  2016,  the  Scheme  is  expected  to  be  rolled-­‐out  to  at  least  seven  regions  by  2019,  and  is  expected  to  be  introduced  first  into  regions  with  poorer  health  outcomes  and  higher  poverty  levels.8    

RBF  is  a  major  reform  and  an  opportune  moment  for  learning  about  a  crucial  phase  in  the  policy   process   in   relation   to   a   key   health   policy   and   systems   issue.   While   scaling   up   of  effective  health   interventions  or  strategies   is  considered  essential  to  benefit  more  people,  there  is  limited  documentary  evidence  on  how  to  ensure  the  effectiveness  of  such  a  scaling  up  process,  particularly  on  RBF.                                                                                                                                    4  Since  the  early  1990s,  CORDAID  had  been  funding  health  care  activities  executed  by  the  Roman  Catholic  Church  in  five  rural  areas  in  Tanzania  -­‐  Arusha,  Bukoba,  Rulenge  Kigoma  and  Sumbawanga.  In  2006  following  positive  experiences  with  PBF  in  Cambodia,  Haiti  and  Rwanda,    Cordaid    decided  to  change  its  funding  strategy  in  Tanzania  to  a  more  output  based  approach.    Cordaid  introduced  PBF  in  64  health  facilities  (13  hospitals,  12  health  centres,  39  dispensaries)  in  the  five  Catholic  dioceses.  1st  phase  2006-­‐2008,  2nd  phase  2009-­‐2011.  Initial  CORDAID  policies  were  not  aligned  to  national  policies  and  practices  -­‐  PBF  was  implemented  by  faith  based  facilities  using  “parallel  structures”  (diocesan  health  offices).  Due  to  subsidy  cuts  by  the  Government  of  Netherlands,  in  2011  Cordaid  ended  her  support  to  the  PBF  initiative  in  Tanzania,  coinciding  with  the  launch  of  the  P4P  pilot.  See  Table  9  for  Cordaid’s  PBF  scheme.  5  Though  Norway’s  interest  was  not  influenced  by  CORDAID’s  work  in  Tanzania,  reports  of  positive  experience  with  PBF  in  Rwanda  where  CORDAID  had  a  key  role  was  very  influential.    6  With  technical  support  from  the  London  School  of  Hygiene  and  Tropical  Medicine,  UK  and  Chr.  Michelsen  Institute  (CMI),  Norway.  7  See  Table  11  for  a  summary  of  the  evaluation  findings.  8  RBF  for  Health  in  Tanzania.  MoHSW,  Health  Financing  TWG  presentation  on  28th  August  2015.  

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We  contribute  through  the  use  of  the  historical  case  study  to  identify  bottlenecks  as  well  as  catalysts  for  improvements  in  the  RBF  process.  In  particular  we  detail  a  case  study,  as  part  of  a  multi-­‐country  research  initiative  supported  by  the  Alliance  for  Heath  Policy  and  Systems  Research   (AHPSR)9,   tracking   the   RBF   policy   formulation   process   and   early   scaling   up  preparations   in   Tanzania.  We   draw   lessons   for   further   scaling   up   and   sustaining   such   an  initiative,  nationally  and  internationally.  

The  effect  of  the  RBF  strategy  will  depend  on  the  implementation  arrangements  and  their  involvement   with   the   broader   constituencies   in   the   health   sector,   governmental,  development   partner,   and   civil   society.   The  way   policies   are   shaped   subsequently   affects  implementation  and  the  likelihood  of  success  (Gilson,  Doherty  et  al.  1999).    

1.2 Objectives  

This  research  aims  to:  (1)  document  and  analyse  the  evolution  of  RBF  policy,  concepts  and  approaches   in   Tanzania,   from   the   introduction   of   the   pay   for   performance   concept   in  November   2006   to   the   adoption   of   the   current   RBF   scheme   and   early   scale   up   plans   in  September  2015;  and  (2)  identify  enablers  and  barriers  to  scaling  up.    We  explain  why  the  policy  process  unfolded  the  way  it  did  to  understand  the  decision  to  scale  up  and   identify  how  each  step  of  the  policy  process  has  contributed  to  strengthening  or  weakening  national  ownership   to   RBF.   Recognizing   the   complexities   behind   the   blanket   term   of   national  ownership,   we   mean   here   a   level   of   commitment   and   support   to,   and   by,   national  institutions  (governmental  and  non-­‐state)  that  include  a  mixture  of:  financing  at  central  and  local   government   level;   donor   financing;   inclusion   in   national   strategy;   ministerial  coordination   and   technical   implementation;   participation   in   decision   making   processes,  including   in   the   design,   coordination   and   evaluation   of   the   programme;   and   government  decision  making.  

 

   

                                                                                                                         9  AHPSR  multi-­‐country  research  initiative  is  funded  by  Norway  

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2. Methodology  

2.1 Research  Design  

This  research   involves  an  analysis  of   the  RBF  policy  process,   retrospectively  over  an  eight-­‐year   period   from   December   2006   to   November   2014,   and   prospectively   from   December  2014   to   September  2015.  We  examine   the  evolution  of  RBF  policy   and  programmes  over  this  time  period.    

2.2 Data/data  collection  

The  research  was   informed  by  four  sources  of  data:  document  review;  direct  observations  through   participation   in   technical  meetings   and  workshops   to   assess   the   progress   in   the  evolution  of  RBC  policy  and  programmes;   in-­‐depth  key  informant  interviews  at  the  central  level   with   a   cross   section   of   policy   and   institutional   actors   involved   in   the   RBF   dialogue  process  (see  Annex  A  for  a   list  of  key   informants   interviewed);  and  a  field  visit  to  the  RBF  pilot  district  to  get  some  insights  into  preliminary  reactions  and  opinions  regarding  the  RBF  intervention,  as  well  as  level  of  preparedness  to  start  piloting  the  RBF  scheme  (see  Table  1).  

Interviews   were   conducted   by   five   senior   researchers   trained   in   qualitative   research  methods  (one  social  scientist,  three  health  economists,  one  public  health  professional)  and  one   junior   social   scientist.   A   total   of   26   in-­‐depth   interviews   were   conducted   with  stakeholders   at   the   central   level   (government   officials   and   representatives   from  development   partner   institutions,   non   governmental   organisations   and   research  institutions).    Additionally,  nine  semi-­‐structured  interviews  were  held  with  key  informants  in  the  pilot  district.  Altogether,  twenty-­‐two  indepth  and  nine  semi-­‐structured  interviews  were  conducted   face  to   face,  and  4   interviews  were  conducted  via  skype.  All  except  one  of   the  face  to  face  interviews  was  conducted  in  teams  of  two  or  three.    Additionally,  12  follow-­‐up  interviews  were  carried  out  by  the  Principal  Investigator  after  receiving  feedback  from  the  key   informants   on   the   almost   final   draft   report.   The   team   of   interviewers   were   closely  managed  and  overseen  by  the  Principal  Investigator.    

Where  respondents  consented,  we  used  sound  digital  recorders  to  record  interviews  (in  23  interviews).     In  the  remaining  12   interviews  (nine  from  the  pilot  district,  two  central   level,  one  skype)  where  tape  recording  was  not  authorised,  one  of   the   interviewing  researchers  observed   interviews   and   was   responsible   for   compiling   detailed   notes   summarising   the  content  of   the   interview.    Recorded   interviews  were,   transcribed  verbatim  and   translated  from  Kiswahili   into  English  (where  interviews  were  carried  out  in  Kiswahili)  by  the  team  of  trained  researchers  who  conducted  the  interviews.  Expanded  notes  were  also  written  soon  after  each  interview  consisting  of  detailed  notes  (including  quotes  to  illustrate  interviewees'  voices).    A  brief  report  was  written  by  the  two  field  researchers  from  their  five-­‐day  field  visit  to  Kishapu  pilot  district  in  Shinyanga  region.  (See  Annex  B  for  a  summary  of  this  report).  

We  engaged  in  an  iterative  data  collection  process.  A  preliminary  documentary  review  of  all  internal  and  external  secondary  data  provided  relevant  information  on  the  evolution  of  RBF  policy   and   programmes   from   the   introduction   of   its   concept   in   end   2006   to   its   status   in  September   2015   along   three   broad   key   dimensions   of   scaling   up:     horizontal   (population  coverage),   functional   (service   coverage)   and   vertical   (integration  with   the   health   system)  (Hartmann  2008,  WHO/ExpandNet  2010).  The  initial  review  process  helped  identify  our  key  

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informants.   The   information   provided   by   the   key   informants   assisted   in   further  identification   of   additional   relevant   documents   and   key   informants.   This   process   helped  triangulate  our  earlier  results  and  further  guide  us  to  the  next  analytical  phase  of  assessing  the  outcome  of  the  scale  up  across  time  by  applying  the  health  policy  triangle  proposed  by  Walt   and   Gilson   (1994)   which   comprises   of   four   components   –   policy   process,   content,  context  and  actors  –to  interpret  our  data.    

Table  1.  Data  sources  i.  Documents  reviewed  

• Published  RBF  research  • RBF  related  policies  and  reforms  from  2007  onwards  • Independent  pilot  evaluations  –  progress  reports  and  dissemination  of  findings  (December  2013)  • Progress   reports   and   minutes   of   Health   Financing   and   Human   Resource   for   Health   (HRH)  

Technical   Working   Group   meetings,   Health   Development   Partner   Group,   P4P   advisory   board  meetings  

• Reports   from   Joint   Annual   Health   Sector   Review,  Mid   Term   Technical   review   and   Big   Results  Now  Lab    

• Workshop  presentations,   including  national  RBF  preparation  meeting  in  Bagamoyo  (Nov  2013),  National  P4P  Stakeholders  Best  Practices  Meeting  (early  2013),  Cordaid  International  (Nov  2012)  and  National  (2013)  PBF  Forum,  National  Conference  on  HRH  (2013)  

ii.  Direct  observations  of  technical  meetings  and  workshops  to  assess  progress  in  the  evolution  of  RBF  policy,  concepts  and  approaches.  Health  Financing  Technical  Review  Meetings  (6),  National  Workshops  (Global  Financing  Facility  (GFF)  (2),  Social  Protection  (SP)  National  Meeting  (4),  Nutrition  Multisectoral  Meeting  (1),  HSSPIV  Steering  Committee  Meetings  (1),  Health  Financing  Strategy  (HFS)  Development  Workshops  (1)10  iii.  Key  informant  interviewees  (KIIs)  

Institutions   Number   of   Institutions/  Departments  sampled  

Number  of  KIIs  

Development   Partners   (representatives   of   health  development  partner  institutions  supporting  the  P4P  and/early   RBF   scale   up   preparations,   Health   Basket  Fund  (HBF)  members,  including  those  supporting  the  development  of  the  HFS)  

10   16  

Ministry  of  Health  and  Social  Welfare  –  Central  Level  (representatives   of   departments   involved   in   the  planning   and   implementation   of   the   P4P/RBF  initiative).  

3   5  

Medical  Stores  Department   1   1  Civil   Society   Organisations/   Research  Institutions/Consultancy  Firms  (institutional  memory  relevant  to  P4P)  

4   4  

TOTAL     18   26  iv.  “Rapid  assessment”  field  visit  to  pilot  Kishapu  district  Regional   and   Council   Health   Management   Team  (Kishapu,  Shinyanga)    

2    3  

Health  Service  Providers  (Kishapu,  Shinyanga)   5   611  TOTAL     5   912  

                                                                                                                         10  Number  of  meetings  or  workshops  attended  in  brackets  11  5  In-­‐Charges  of  5  facilities  (1  hospital,  1  health  centre,  3  dispensaries  {1  private,  1  pilot  public  and  1  non-­‐pilot  public)  and  1  CHW.  12  Semi-­‐structured  interviews    

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Ethical   approval   was   obtained   from   the   Institutional   Review   Board   of   the   Ifakara   Health  Institute,  as  well  as  from  the  WHO  Ethics  Review  Committee.  

Verbal   and/or   written   informed   consent   was   obtained   from   all   respondents.   The  information  was  anonymised  and  confidential.  

2.3 Research  Tools  

A   semi-­‐structured   questionnaire   was   developed   to   facilitate   in-­‐depth   interviews   at   the  central  level  (See  Annex  C  for  a  list  of  guiding  questions).  The  tool  was  further  refined  after  piloting  with  a  few  key  informants  and  also  following  the  first  initial  interviews.  

Questions  were  moulded   to   the   specific   target   population  depending  on   their   role   in   the  RBF  policy  formulation  process  and  their  time  availability  for  being  interviewed.  Some  of  the  questions   asked   of   all   stakeholders   at   national   (central)   level   included:   their   involvement  and  role   in  RBF-­‐related  policy   formulation;   the  major  decisions   leading   to   the  RBF  related  policy,   key  decision-­‐makers   and   the  decision-­‐making  process   at   each   step;   the  arguments  for   and   against   the   different   decisions  and   position   of   different   stakeholders;   extent   to  which   major   decisions   were   informed   by   evidence;   degree   of   consensus   amongst   key  stakeholders,  national  and  international,  on  the  way  forward  ;  and  flow  of  information  and  level  of  inclusiveness  among  affected  stakeholders  throughout  the  process    

Informal  discussions  held  with  nine  key  informants  at  the  regional  and  district  level  centred  around  their  overall  awareness  and  opinion  of  the  RBF  intervention  and  the  pilot  that  was  about   to   start   in   their   district   –   who   were   the   key   actors,   if   and   how   have   they   been  involved   in   general   decision   making   processes   during   the   preparatory   phase,   their  preparedness   for   the   pilot,   and   any  major   concerns  with   the   roll   out   plans,   including   the  design  features  (see  Annex  D  for  a  list  of  guiding  questions).  

All   participants   were   given   a   complete   informed   consent   sheet,   which   included   the  certificate  of  consent,  as  well  as  an  information  sheet  with  all  the  necessary  project  details  -­‐  purpose,   objectives   and   outcomes   of   the   research   (see  Annex   E).   The   form   stressed   that  their  participation  is  voluntary,  they  are  free  to  choose  to  participate  or  not,  and  they  can  choose  to  withdraw  at  any  time  with  no  adverse  consequences  arising  from  their  decision.  The   form   also   included   the   name   and   contact   information   of   the   appropriate   contact  persons   should   the   participant   have   any   concerns   or   queries   about   his/her   rights   as   a  research  participant,  or  on  the  nature  of  the  research  project.    

2.4 Data  Analysis  

We  developed  a  timeline  using  Excel  software  to  situate  key  steps  towards  the  RBF  scale  up.  We  report  the  multi-­‐dimensional  evolution  of  the  RBF  policy  on  a  timeline.  

Data   from   indepth   key   informant   interviews  were   classified   and  manually   coded  applying  thematic  content  analysis.  Some  of  the  broader  themes  included:    key  milestones  leading  to  the   RBF-­‐related   policy;   the   decision   making   processes   at   different   stages   -­‐   key   decision  makers,   their   role,   their   views   (arguments   for   and   against);   the   involvement   of   national  stakeholders   in   decision   making   processes;   the   content   and   the   role   of   evidence   in  informing  the  content;  communication  channels;  and  the  national  and  global  policy  context  

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level  which  affected  the  process,  both  within  and  outside  the  health  sector.  

Three  interviews  were  initially  manually  coded  in  parallel  by  the  Principal  Investigator  and  the  two   qualitative   research   scientists.   Through   this   process,   a   codebook  was   agreed   upon   and  used  to  code  the  remaining  data,  leaving  scope  for  themes  to  emerge  in  an  open  and  grounded  way.  Preliminary  analysis  was  undertaken  on  an  on-­‐going  basis,  as  transcripts  and  expanded  notes  and  other  information  from  document  reviews  and  observations  became  available,  with  interviewers   noting   interpretations   and   emerging   hypotheses   for   further   exploration   in  subsequent  interviews.  Emerging  findings  were  reviewed  and  jointly  agreed.  

In   our   analysis,  we   also  paid   particular   attention   to   the  policy   actors   involved   in   the  RBF  scaling  up  process;  the  proponents  and  opponents  of  the  RBF  policy;  and  the  drivers  of  the  RBF  scaling  up  process.    We   investigate  how  the  actors   interacted  among  themselves  and  exercised  their  power  to  influence  the  scaling  up  related  decisions/actions  and  the  reasons  behind   such   decisions.  We  use   stakeholder   analysis   to   analyze   the   power   of   actors,   their  networking   and   political   will   or   position   towards   the   RBF   initiative   in   order   to   clearly  recognize   whether   they   are   enablers   or   hinders   of   the   scaling   up   process.   We   use   the  Forcefield  Matrix  to  see  changing  positions  and  influence  of  stakeholders  regarding  the  RBF  policy  over  time  (Onoka  et  al  2014;  Varvasovszky  &  Brugha  2000),    

2.5 Quality  assurance  

Systems  were  put  in  place  to  ensure  data  quality.  Interviews  were  conducted  by  four  senior  researchers   trained   in   qualitative   research   methods   and   one   junior   social   scientist.   The  team  of  interviewers  were  closely  managed  and  overseen  by  the  Principal  Investigator,  who  was  also  present  and  involved  in  some  of  the  interviews.    To  validate  findings  and  identify  the  most  widely  supported  arguments,  we  triangulated  data  across  respondent  groups  and  looked   for   supporting   documentary   evidence,   where   available.   We   also   compared   and  contrasted   views,   for   example   about   the   origins   of   the   Pay   for   Performance   initiative   in  Tanzania,  or  the  level  of  national  involvement  in  planning  for  the  present  RBF  scale  up,  from  different   stakeholders.   The   fact   that   we   were   seeking   perspectives   of   individuals   from  different   organisations   also   enhanced   our   confidence   that   we   are   presenting   a   balanced  account.  Before  finalizing  the  Tanzanian  case  study,  the  draft  country  case  study  report  was  shared   with   country   stakeholders   for   their   final,   as   well   as   with   the   Institute   of   Tropical  Medicine  (Antwerp),  the  technical  oversight  body.  

   

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3. Results  

The   analysis   of   the   evolution   of   Results   Based   Financing   policy   and   programmes   is  presented  in  two  sections.    

The   first  Section  3.1  summarises   the  national   context  within  which  Tanzania’s  RBF  policy  evolved.    

The   second   section   3.2   describes   and   analysis   the   phased   evolution   of   the   RBF  policy,   concepts   and  programmes   in   Tanzania   from   since   the   inception   of   the   P4P  concept  in  December  2006  to  early  implementation  plans  in  September  2015.    

A  matrix   of   key   events   from   end   2006   to   September   2015   is   presented   in  Annex   F.   And  Annex  G  provides  a  multi-­‐dimensional  evolution  of  Tanzania’s  RBF  from  end  2006  to  early  2015   along   three   broad   key   dimensions   of   scaling   up   -­‐   horizontal   (population   coverage),  functional   (service  coverage)  and  vertical   (integration  with   the  health   system),  and  within  the  national  and  global  context  of  related  events.  

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3.1.  The  national  context:  country  profile  and  health  system  

The  population  of  Tanzania  mainland  was  estimated   to  be  over  43.6  million   in  2012,  with  the  majority  of  the  population  (71%)  living  in  rural  areas  and  dependent  on  underdeveloped  smallholder  primary  agriculture  production  (see  Table  2).  

3.1.1. Socioeconomic  and  health  status  

The  recent  rebasing  of  the  national  account  reveals  a  picture  of  a  country  closer  to  reaching  middle-­‐income   status,   with   current   average   per   capita   income   estimated   at   USD   998   in  2014.   13   However,   despite   a   strong   and   sustained   high   rate   of   GDP   growth   which   has  remained  stable  at  around  7%  for  over  a  decade,  the  overpowering  public  perception  is  that  growth  is  unequal  -­‐  only  a  small  minority  of  Tanzanians  are  benefitting.    The  Gini  coefficient  of  real  per  capita  monthly  consumption  indicates  that  the  level  of  inequality  for  Tanzania  is  approximately  36  in  2011/12,  declining  from  around  39  in  2001–07  The  Tanzania  Mainland  Poverty   Assessment14   shows   that   Tanzania   remains   a   poor   country.  More   than   a   quarter  (28.2%)  of  the  population  are  living  in  poverty,  below  the  basic  needs  poverty  line15,  which  refers  to  the  minimum  resources,  needed  for  physical  wellbeing.  Close  to  a  tenth  (9.7%)  of  the  population  are  extremely  poor  and  cannot  afford  to  buy  basic  foodstuffs  to  meet  their  minimum   nutritional   requirements   of   2,200   kilocalories   (Kcal)   per   adult   per   day16.  Altogether,   around  12  million  Tanzanians,   among   them  10  million   in   the   rural   sector,   still  live   in   poverty;   and   more   than   four   million   citizens   continue   to   be   in   extreme   poverty.  Poverty  is  associated  with  rural  status,  larger  families,  lower  education  and  lower  access  to  infrastructure.  Over  80%  of  the  poor  and  extreme  poor  living  in  the  rural  areas.  

Demographic   and   Health   Survey   and   census   estimates   from   1999   to   2012   suggest   that  Tanzania   has   made   great   strides   in   improving   infant   and   under-­‐five   mortality   rates,   the  maternal  mortality   ratio   remains   unacceptably   high   at   432  deaths   per   100,000   live   births  against   a   backdrop   of   low   facility-­‐based   skill   birth   deliveries   which   is   slowly   increasing-­‐  around   62%   in   2012.  Weaknesses   in   the   health   system   have   had   a   direct   impact   on   the  delivery  of  maternal  and  newborn  services.  Many  poor  rural  women  and  children  encounter  severe  constraints  in  accessing  health  care,  and  the  quality  of  care  delivered  is  substandard  for  various  reasons  (Mamdani  &  Bangser  2004).  They  need  more  health  care,  but  often  get  less  (Smithson  2006).    

Tanzania’s   rank   in   the   UNDP   (United   Nations   Development   Programme)   Human  Development   Index   has   improved   since   1995,   but   its   progress   towards   MDGs   has   been  uneven.17     The   country   is   expected   to   reach   only   three   out   of   eight   MDGs   by   2015   –  combating  HIV/AIDS;  infant  mortality  and  under-­‐five  mortality.    

                                                                                                                           13  Other  2014  estimates  include:  USD  2591  per  capita  (Purchasing  Power  Parity),  USD  930  Gross  National  Income  per  capita,  using  WB  Atlas  Method  (current  US$),  http://data.worldbank.org/country/tanzania,    14  Using  2011/12  Household  Budget  Survey  (HBS)  data  and  the  new  rebased  GDP  figures  released  in    December  2014;  http://www.worldbank.org/en/country/tanzania/overview    15  Estimated  using  the  national  basic  needs  poverty  line  of  T  Sh  36,482  per  adult  per  month  (translates  approximately  into  USD1/capita/day  at  2005  purchasing  power  parities,  lower  than  the  international  poverty  line  of  USD  1.25/capita/day).  The  incidence  of  poverty  in  Tanzania  is  about  15  percentage  points  higher  when  using  the  international  poverty  line  of  $1.25  per  person  per  day.  16  Estimated  using  the  national  food  poverty  line  of  T  Sh  26,085  per  adult  per  month  17  http://www.worldbank.org/en/country/tanzania/publication/tanzania-­‐mainland-­‐poverty-­‐assessment-­‐a-­‐new-­‐picture-­‐of-­‐growth-­‐for-­‐tanzania-­‐emerges  

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Table  2.    Key  economic  and  health  status  indicators  for  Tanzania  Mainland  

Economic  indicators     Data  Source  Population  (million)     43.6  (2012),  47.8(2015)18   NBS  2012  census  data,  MoHSW  2015  Gross  Domestic  Product/  capita  (current  USD)  

998  (2014)19     Tanzania  Mainland  Poverty  Assessment  Report  (http://www.worldbank.org/en/country/tanzania)  

GDP  growth   Around  7%  (stable  for  a  decade)    

Tanzania  Mainland  Poverty  Assessment  Report  

Gini  coefficient  (of  consumption  per  capita)    

0.39  (2001-­‐07),  0.36  (2011/2012)  

Tanzania  Mainland  Poverty  Assessment  Report  

Poverty  Head  Count  (HBS):  

• Basic  Needs  Poverty  Rate  

Extreme  poverty  head  count  (%)  

• Food  poverty  rate  

 34%  (2007),  28.2%  (2011/2012)      11.7%  (2007),  9.7%  (2011/2012)  

Tanzania  Mainland  Poverty  Assessment  Report  20  

Poverty  rate     43.5%  (<  $1.25/  day),  90%  (<  $3/  day)  

Tanzania  Mainland  Poverty  Assessment  Report  

Health  status  indicators   Data  Source  Under  five  mortality  rate  (per  1000  live  births)  

147  (1999),  112  (2005),  81  (2010),  54  (2013)  

TDHS  1999,  2005,  2010,  Census,  SAVVY  (MoHSW  2015)  

Infant  mortality  rate  (per  1000  live  births)  

99/1000  (1999),  68/1000  (2005),  51/1000  (2010),    45  (2012)  

TDHS,  NBS  Census  2012,  SPD,  SAVVY  (MoHSW  2015)  

Neonatal  Mortality  rate  (per  1000  live  births)  

32  (2005),  26  (2010)   TDHS  2005,  2010  (MoHSW  2015)  

Maternal  mortality  ratio  (per  100,000  live  births)  

578  (05),  454  (2010),  432  (2012)  

TDHS  2005,  2010,  NBS  Census  2012  (MoHSW  2015)  

Life  expectancy  at  birth  (years)  

61  (Overall),  63  (Female),  60  (Male)  

Census  2012  (MoHSW  2015)  

Source:   MoHSW.   2015.   Health   Sector   Strategic   Plan   (HSSPIV),   July   2015   –   June   2020;   Service  Availability  Readiness  Assessment  (SARA)  2012,  Tanzania  Demographic  Health  Surveys  (TDHS)  2005,  2010;   World   Bang   Group.   Undated.   Tanzania   Mainland   Poverty   Assessment.  www.worldbank.org/tanzania    

3.1.2  National  development  and  health  policy  context  

Tanzania’s   morbidity   and   mortality   rates   have   made   health   a   key   priority,   addressed   in  various   global   and   national   commitments   such   as   the   Millennium   Development   Goals,  Tanzania’s  Vision  2025,  the  National  Strategy  for  Growth  and  Reduction  of  Poverty  (NSGRP-­‐MKUKUTA),   Tanzania’s   Health   Sector   Strategic   Plan   III   (HSSP   III)   (MoHSW   2008)   and   the  Primary   Health   Services   Development   Programme   (PHSDP-­‐MMAM)   2007-­‐2017   (MoHSW  2007)  (see  Figure  1).  Tanzania  has  developed  a  Maternal  Newborn  and  Child  Health  Strategic                                                                                                                            18  NBS  2015  projection  using  an  average  annual  growth  rate  of  2.7%  19  Other  2014  estimates  include:  USD  2591  per  capita  (Purchasing  Power  Parity),  USD  930  Gross  National  Income  per  capita,  using  WB  Atlas  Method  (current  US$),  http://data.worldbank.org/country/tanzania,  20  WB  poverty  assessment  report  uses  HBS  2011/12  and  new  rebased  GDP  figures  released  in    Dec  2014  (WB  undated)  

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Plan   (2008   –   2015),   the   One   Plan,   committed   to   reducing   maternal,   newborn   and   child  mortality,   in   line   with   the   New   Delhi   Declaration   2005   (MoHSW   April   2008,   2014).   The  Tanzania  Partnership  for  Maternal,  Newborn  and  Child  Health  (TPMNCH),   launched  in  April  2007,   is   incorporating  child  health   interventions   into  this  plan.  The  Maternal  Newborn  and  Child  Health  Strategic  Plan  is  bringing  maternal,  newborn  and  child  health  interventions  onto  the   agenda;   and   prioritizing   improved   coordination   of   interventions,   service   delivery,  alignment  of  resources  and  standardization  of  monitoring      (MoHSW  2013).    

 

Figure  1.  Road  to  Tanzania’s  Vision  2025  

Source:  MoHSW  December  2014.  

 

Altogether,   there   is   no   shortage  of   good  policies,   strategies   and  programmes   at   national,  sectoral   and   local   government   level.   However,   the   policies   need   to   be   effectively  implemented.   Whether   the   majority   of   the   population   benefits   from   such   policies   and  programmes,  will  depend  ultimately  on  how  available  benefits  and  resources  are  allocated  and  distributed.    

3.1.3  Health  sector  context  

Tanzania   is   fortunate   to   have   an   extensive   network   of   health   facilities   throughout   the  country21,   about   8,215   health   facilities,   of   which   around   84%   are   owned   by   the   public  sector,  a  mark  of   its   long  standing  commitment  to   improving  the  health  of  the  population  through  ensuring  their  access  to  essential  quality  health  services  (MoHSW  2015,  p13).    

                                                                                                                         21  The  majority  of  the  population  gets  their  health  services  from  primary  health  care  facilities  (MoHSW  2015,  p13)  

3

2014 onwards Without Healthy population, Tanzania will NOT achieve its aspiration

1999 Tanzanian Government launched

Tanzanian Development Vision 2025 and healthcare has been one of the

primary focuses

2000 - 2013 Various Healthcare-centric

programmes were developed over the years aiming to achieve TDV 2025’s goal

2013 Current results 50% of HSSP III’s plans are NOT on-track

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egestas.

Many programmes and plans are in place but have not yield favorable results, it’s a long journey to achieve Tanzania’s Aspiration

HSSP

Mkukuta

MTR 2013

2000 – 2013 The Healthcare sector is not doing well among the peers...

2014 onwards Long way to catch up to

catalyse the effort in achieving the aspired productive & healthy Tanzanian population by 2025

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According   to   the   Mid-­‐term   Review   (MTR)   for   the   Health   Sector   Strategic   Plan   (HSSP)   III  (2009-­‐2015),  though  the  sector  is  making  progress  in  all  strategic  areas,  the  overall  pace  is  slow,  with  more  progress  in  institutional  development  (policies,  strategies,  guidelines,  work  plans,   etc.)   than   in   improving   service   delivery   (MoHSW,   IHI,   NIMR,   WHO   2013;   MoHSW  2013,   October   2013).   The  MTR   suggested   greater   emphasis   on   outcomes   in   combination  with   sustainable   service   delivery   systems,   as   well   as   engaging   communities   towards  strengthening  the  health  services  and  improving  quality.    

A   2015   World   Bank   report22   notes   that   a   range   of   serious   health   system   challenges  contribute  to  such  poor  health  outcomes.  Three  critical  supply  side  challenges  are  identified.  

Firstly,  contrary   to   the  goals  of   the   third  Health  Sector  Strategic  Plan  which  committed  to  universal  health  coverage  via  social  health  insurance23,  health  financing  is  highly  dependent  on  external  support   (which  accounted   for  47-­‐49%  of   total  public  expenditure  on  health   in  2011/12);   and   fragmented   with   a   significant   share   being   off-­‐   budget.   Aside   from   poor  budget   execution   and   often   delayed   release   of   funds,   the   share   of   health   in   the  Government’s  budget  is  inadequate  and  declining.  The  public  health  budget  share  declined  from   10.5%   (2010-­‐11)   to   8.1%   (2013/14),   well   below   the   Abudja   target   of   15%   of   total  government   budget   to   the   health   sector.   It   has   risen   slightly   in   FY2014/15,   reversing   the  earlier   trend,   but   with   the   inclusion   of   CFS   it   has   remained   static.   Resource   shortages  matter.   The   burden   of   paying   for   health   falls   heavily   on   households.   In   2011/12,   out-­‐of-­‐pocket   payments   were   estimated   at   25%   of   all   health   spending   in   the   country,   a   slight  decline   from  2009/10,  but   still   above   the   recommended   top   limit  of   20%   (Mama  Ye!   July  2015).   The  poorest  are   likely   to  be  excluded   from  care  or  pushed   further   into  poverty  by  unsustainable  payments  (Mtei  et  al  2014).  Available  evidence  suggests  that  exemptions  and  waivers   aimed   at   providing   financial   protection   for   the   most   vulnerable   groups,   are   not  systematically  implemented  and  are  not  effective  as  a  means  of  protecting  vulnerable  social  groups  and  the  poorest  of  the  poor  (Mamdani  and  Bangser,  Mtei  et  al  2015).  

The  Government  had  set  a  target  of  enrolling  45%  of  the  population  in  prepayment  schemes  by   2015   towards   raising   additional   revenue   for   the   health   sector   and   provide   flexible  funding  to  health  facilities  (Haazen  2011,  MoHSW  October  2013).  But  formal  and  informal  health   insurance   mechanisms   have   had   limited   success,   covering   a   minority   of   the  population.  According  to  NHIF  data  from  2013,  only  19%  of  the  population  had  enrolled  in  any  one  of  the  social  health  insurance  schemes,  falling  well  below  the  set  target  (quoted  in  MoHSW  2015).  Some  8.7%  were  enrolled  in  voluntary  CHF  schemes  in  2013/2014,  ranging  from  29.8%  in  Singida  to  1.3%  in  Kagera  –  altogether  a  very  low  coverage  given  that  close  to  three  fourths  of  the  population  is  working  in  the  rural  informal  sector  (see  Table  3).  

   

                                                                                                                         22  The  World  Bank  May  2015.  23  A  key  part  of  the  HSSP  III  strategy  for  financing  the  health  sector  was  to  increase  complementary  funding  consisting  of  the  Community  Health  Fund  (CHF)  membership  fees,  user  fees,  and  insurance  reimbursements  including  National  Health  Insurance  Fund  (NHIF)  and  Social  Health  Insurance  Benefit  (SHIB)  (MoHSW  October  2013).  The  NHIF  was  introduced  in  1999  to  provide  financial  protection  for  formal  public  sector  employees  and  the  CHF  was  enacted  in  2001  as  a  prepayment  scheme  for  the  informal  sector;  subsequently  in  July  2006,  the  mandatory  National  Social  Security  Fund  for  employees  in  the  formal  and  semi-­‐formal  sector  introduced  the  SHIB  scheme.  While  contribution  to  the  NHIF  is  mandatory  for  all  public  sector  civil  servants;  membership  to  CHF  is  voluntary;  and  enrollment  to  SHIB  is  voluntary  and  free  for  all  NSSF  members  though  they  have  to  register  for  it  (Dutta  2015,  Haazen  2011).  

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Table  3.    Key  health  financing  indicators  for  Tanzania  Mainland  

Health  financing  indicators24   Data  Source  Per  capita  health  spending  (budget  per  capita,  US$)  

Nominal:  22.45  (2010/11),  17.62  (2011/12),  18.03  (2012/13),  19.82  (2013/14)  Real:  11.13  (2010/11),  7.94  (2011/12),  7.30  (2012/13),  7.48  (2013/14),  7.63  (2014/15)  

PER  2014,  MoHSW  2014b  

Share  of  total  government  expenditure  (budget)  allocated  to  health  (%)  (Excl.  CFS)  

Exclude  CFS:  11.6  (2006/7),  12.3  (2010/11),  8.9  (2013/14),  9.1  (2014/15)  Include  CFS:  10.5  (2006/7),  10.5  (2010/11),  8.1  (2013/14),  8.1  (2014/2015)  

PER  presentation  to  JAHSR  2014,  MoHSW  2015  

Government  expenditure  on  health  (GHE)  (as  share  of  total  government  expenditure)  

7%  (2011/12)   NHA  2011/2012,  MoHSW  2015  

‘Public”  payments  as  %  total  health  expenditure  (public  sector  financing)  

28  %  (2005/06),  26  (2009/10),  22  (2011/12)    

NHA  2011/12,  MoHSW  2015  

GHE  as  %  of  total  health  expenditure    

21%  (2011/12)   NHAs  2011/12,  MoHSW  2015  

Out-­‐of-­‐pocket  payments  as  %  t     25  (2005/06),  32%  (2009/10),  25%  (2011/12)25  

NHAs  2011/12,  MoHSW  2015  

Development  Partners  resources  for  health  as  %  of  total  public  expenditure  on  health    

44  (2005/06),  40  (2009/10),  47-­‐49  (2011/12)    

NHA  2011/12,  MoHSW  2014a  

Other  private  resources  for  health  as  %  of  total  PHE  

3  (2005/06),  2  (2009/10),  5  (2011/12)  

NHA  2011/12,  MoHSW  2014a  

%  Population  enrolled  in  any  of  the  social  health  insurance  schemes  (NHIF,  NSSF-­‐SHIB,  CHF,  TIKA,  CHIF,  and  others)  

a. Estm  CHF  coverage  (%)  

19  (2013)      7.8  (2010/11),  8.9  (2011/12),  7.4  (2012/13),  8.7  (2013/14)    

NHIF  2013  data  in  MoHSW  (2015)    PER  2014,  MoHSW  2014b  

Spending  by  disease  in  2011/12   • HIV/AIDS,  TB  and  malaria:  45%  of  THE  

• Reproductive  and  Child  Health  12%  of  THE  

 

NHA  2012,  MoHSW  2014a  

Source.  MoHSW.  2015.  Health  Sector  Strategic  Plan  (HSSPIV),  July  2015  –  June  2020;  MoHSW.  5  November  2014a.  National  Health  Accounts  (NHAs)  2011/12.  Power  point  presentation  to  Technical  Review  Meeting;  MoHSW.  5  November  2014b.  Public  Expenditure  Review  –  PER  2013/2014  Update.    

Secondly,   the   health   system   is   currently   coping  with   low  worker  motivation   coupled  with  severe  shortages  of  staff,  medicines  and  supplies.  According  to  a  2008  survey,  on  average,  health   facilities   had   54%   fewer   health   workers   in   practice   than   is   required   by   Tanzanian  

                                                                                                                         24  All  per  capita  expenditure  data  are  in  the  unit  of  current  US$  (i.e.  at  exchange  rate  rather  than  PPP).  25  PPT  presentation  (4  Nov  2014)  to  HF-­‐TWG  quotes  27%  in  2011/12,  using  the  same  source  (NHA  2011/12)  

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national   standards   (SIKIKA   2010).   Another   2013   survey   found   that   only   31%   of   health  professionals  were  stationed  in  rural  areas,  despite  close  to  three  fourths  of  the  population  living   in   these   areas   (IHI   2013).   The  Human  Resource   for  Health   (HRH)   Public   Expenditure  Review  (PER)  of  2010  reported  the  HRH  gap  to  be  about  60%.  The  health  sector  is  challenged  with  production,  attrition  and  retention  of  health  professionals  (MoHSW  HRH  Report  2011,  quoted   in  MoHSW  undated,  p17)  (see  Table  4).  A  2013  survey  by  TWAWEZA  suggests  that  about  26%  of  health  facility  heads  said  that  a  lack  of  medicines  was  the  main  problem  facing  their  facility  and  nearly  41%  of  the  population  were  not  able  to  obtain  the  prescribed  drugs  from  the  facility  they  visited  (TWAWEZA  May  2014).  For  example,  Tanzania  spends  less  than  US$1   per   capita   on   medicines   every   year   compared   to   a   national   target   of   US$2,50   and  global  health  initiative  guidelines  of  US$5  (MoHSW  2013,  in  TWAWEZA  May  2013).  

 

Table  4.    Key  health  service  coverage  and  delivery  indicators  for  Tanzania  Mainland  

Service  coverage  and  delivery  indicators   Data  Source  Antenatal  care  coverage:  %  pregnant  women  with  first  visit  before  12  weeks  gestational  age    

15%  (2010),  15%  (2014)   TDHS  2010,  HMIS  2014  (MoHSW  2015)  

Antenatal  care  coverage:  %  pregnant  women  who  managed  4  visits    

43  (2010),  40  (2014)   TDHS  2010,  HMIS  2014  (MoHSW  2015)  

%  Deliveries  assisted  by  skilled  health  attendants  

47  (2005),  51  (2010),  69  (2014)  

TDHS  2005,  2010,  HMIS  2014    (MoHSW  2015)  

%  Dispensaries  and  health  centres  that  provide  BEmONC    

20  (dispensaries,  2012),  39  (2012,  health  centres)  

2012  SARA  (MoHSW  2015)  

%  Health  centres  and  hospitals  that  provide  CEmONC    

9  health  centres  (2012),  73  hospitals  (2012)  

SARA  2012,  MoHSW  2015  

Density  of  Nurses  and  Midwives  –  _entire  country  per  10,000  population    

5.60  (2014)  26    

MoHSW  2015  

Source:  MoHSW.  2015.  Health  Sector  Strategic  Plan  (HSSPIV),  July  2015  –  June  2020;  Service  Availability  Readiness  Assessment  (SARA)  2012,  Tanzania  Demographic  Health  Surveys  (TDHS)  2005,  2010    

Thirdly,   the   Government   operates   a   decentralized   health   system   organized   around   three  functional  levels:  council  (primary  level  served  by  dispensaries  and  health  centres),  regional  (district   hospitals   at   secondary   level),   and   referral   tertiary   level   hospitals.   Within   the  framework  of  the  ongoing  local  government  reforms,  the  current  27  regional  and  162  local  government   authorities   (LGAs,   or   councils)   are   responsible   for   delivering   health   services                                                                                                                            26  MOHSW,  Human  Resources  Planning  Division,  Human  Resources  for  Health  Information  Systems  (HRHIS)  and  Training  Institutions  Information  System  (TIIS)  (2014)  

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within  their  areas  of  jurisdiction,  and  report  administratively  to  the  Prime  Minister’s  Office  –  Regional   Administration   and   Local   Government   (PMO-­‐RALG).   The   Councils   the   most  important   administrative   and   implementation   units   for   public   services.   The   MoHSW   is  responsible   for   policy   formulation,   supervision   and   regulation   for   all   health   services  throughout  the  country,  as  well  as  playing  a  direct  role  in  the  management  of  tertiary  health  services.  The  process  of  decentralization  by  devolution  has  never  been  adopted  in  spirit  even  though   it   has   been   an   official   policy   for   over   20   years.   For   example,   health   facilities   are  hindered  in  their  operation  with  limited  financial  autonomy  to  utilize  their  own  funds.  Most  primary   health   care   (PHC)   facilities   do   not   even   have   a   bank   account.   Funding   for   PHC   is  channeled   to   local   government   authorities   that   can   limit   resources   reaching   lower   levels  [MoHSW  undated].  

To  intensify  the  response  to  health  system  challenges  as  identified  in  the  mid-­‐term  review  of   the   third  Health   Sector   Strategic   Plan,   the  Government  has   recently   embarked  on   two  major   initiatives:   the  2015-­‐2018  Big  Results  Now   in  Health   (BRN   in  Health)27   and  Results-­‐based  Financing   (RBF).  The   final  health  Big  Results  Now  framework  released   in  early  2015  includes   improved   primary   health   care   as   the   outcome,   with   a   focus   on   four   key   result  areas:   human   resources   for   health,   health   commodities,   health   facility   performance  management   and   reproductive,  maternal,   neonatal   and   child   health.   BRN  Health   aims   to  facilitate  the  achievement  of  Tanzania’s  Development  Vision  2025  and  reduce  maternal  and  neonatal   mortality   through   improving   performance,   governance   and   accountability   in  primary  health  care  (PHC)    (MoHSW  2015).    

The   RBF   initiative   aims   to   enhance   provider   accountability   for   results   and   encompasses  broader   health   system   strengthening   measures.   Both   in   terms   of   health   systems  strengthening   and   the   improvement   of   health   service   delivery,   RBF   has   the   potential   to  incentivize  multiple   levels   of   the  health   system   for   both  quality,   and  quantity,   of   primary  health  care  services  at  dispensaries,  health  centers  and  district  hospitals  [MoHSW  undated,  2015].    

Both  the  BRN  and  RBF  initiatives  are  embedded  in  the  medium-­‐term  Health  Sector  Strategic  Plan  (HSSP)  IV  that  will  guide  the  health  sector  from  2015  to  2020  (MoHSW  2015).    

It   is   noteworthy   that   issues   linked   to   health   financing   strategy   and   human   resource   for  health   (HRH)  were  noted  to  be  among  the  core  priorities  at   the  2011  Joint  Annual  Health  Sector  Review,  culminating  in  the  first  national  HRH  conference  in  September  201328,  with  keynotes  by  President  Kikwete  and  ex-­‐President  Benjamin  Mkapa  and  a  focus  on  prioritising  human   resource   for   health   in   Tanzania   towards   improving   health   services   and   achieving  MDGs.      

 

 

                                                                                                                         27  The  BRN  initiative  was  unveiled  by  President  Kikwete  in  2013,  inspired  by  a  similar  Malaysian  programme  in  an  effort  to  transition  the  country  from  low  to  middle-­‐income  economy.  BRN  focused  on  seven  national  key  results  areas:  Agriculture,  Education,  Energy  &  Natural  Gas,  Resource  Mobilization,  Transport  and  Water.  In  2014  Health  was  added  as  the  eighth  national  key  result  area.  A  BRN  Health  Lab  involving  a  cross-­‐section  of  key  stakeholders  discussing  fundamental  health  system  constraints  and  future  priorities  was  held  over  a  six  week  period  from  Sept.  22-­‐Oct  31,  with  the  World  Bank  was  leading  the  health  commodities  and  health  performance  working  groups.  28    www.afro.who.int/en/tanzania/press-­‐materials/item/5848-­‐tanzania-­‐hosts-­‐the-­‐nationa-­‐human-­‐resource-­‐for-­‐health-­‐conference-­‐.html  

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3.1.4  Health  Financing  Strategy  (HFS)  

The  MoHSW  has  been  working  on  a  comprehensive  health  financing  strategy  for  some  time,  with   assistance   from   Providing   for   Health   (P4H).29   There   have   followed   various   drafts   of  health   financing   system   analysis,   several   health   financing   strategy   workshops   from   2011  onwards,  a  WHO  Health  Sector  Cost  Drivers  Study,  a  Health   Insurance  Regulation  Study,  a  nine  main  options  paper  and  a  fiscal  space  options  paper.  Supported  by  the  United  States  Agency  for  International  Development  (USAID),  a  partner  in  the  local  P4H  network,  updated  National  Health  Accounts  (NHA)  for  the  financial  year  2009/10  were  also  launched,  showing  increasing   out   of   pocket   spending   -­‐   a   set-­‐back   on   the   path   to   UHC   and   financial   risk  protection.   Subsequently,   a  high-­‐level   Interministerial   Steering  Committee   (ISC)   for  health  financing  strategy  development  was  launched  in  2012  under  the  leadership  of  the  MoHSW  and  strongly  supported  by  P4H  partners.  The  inter-­‐ministerial  steering  committee  discussed  options   for   the   consolidation   of   risk   pools,   revenue   collection,   purchasing,   and   benefit  packages,  and  a  consensus  emerged  that  the  Strategy  should  be  focused  on  a  single  national  health  insurer.    

A  final  Health  Financing  Strategy  ready  for  Cabinet  submission  is  almost  in  place,  reportedly  incorporating   RBF,   aligning  with   Big   Results   Now   targets,   and   addressing   parallel   funding  flows.   The   Strategy   highlights   guiding   principles   of   equity,   solidarity,   transparency,  sustainability,  and  efficiency.  It  strives  to  improve  the  health  insurance  coverage,  especially  in   the   informal   sector,   finding   a   better   way   of   protecting   the   poor   against   catastrophic  health  care  payments  and  promoting  universal  access  to  an  essential  health  care  minimum  benefit   package   (Mtei   et   al   2014).   The   process   of   lobbying   for   government   support   &  political  leverage  has  begun.    

Achieving  Universal  Health  Coverage  (UHC)  has  been  a  key  priority  since  post  independence  and  further  reiterated  in  the  National  health  policy  and  Health  Sector  Strategic  Plan  (HSSP)  III,  2008-­‐2015  (MoHSW  2008),  and  now  HSSP  IV  (2015-­‐2020)  (MoHSW  2015).  

   

                                                                                                                         29  P4H  network  was  launched  as  a  political  initiative  for  Social  Health  Protection  at  the  2007  G8  summit  and  since  then  has  evolved  into  an  innovative  global  network    (a  mix  of  multi-­‐and  bilateral-­‐  development  partners  and  investors)  for  Universal  Health  Coverage/Social  Health  Protection  (www.p4h-­‐network.net)  

 

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3.2. A   chronological   analysis   of   the   results   based   financing   policy  formulation  process  

Sixth  distinct  phases  to  the  policy  progression  process  have  been  identified.  In  brief:  

The   first  phase   from  beginning   in  2006  and  continuing   to   this  day  summarises   the  build  up  of  the  global,  regional  and  national  political  momentum  for  MDGs  4  and  5,  the  context  within  which  Tanzania’s  RBF  policy  evolved.  

The   second   phase   briefly   analyses   the   various   attempts   made   in   2007   towards  generating   a   broader   buy   in   and   building   a   national   consensus   for   a   pay   for  performance  initiative  in  Tanzania.  

The  third  phase  details  the  events  from  2007  to  2009  leading  to  the  development  of  the  first  national  design  and  the  subsequent  the  implementation  of  the  first  national  pay  for  performance  scheme,  albeit  unsuccessfully.  

The   fourth   phase   from   2010   to   2013   pays   attention   to   the   implementation   and  evaluation  of  the  Pwani  Pay  for  Performance  Pilot.  

The   fifth   phase   from   June   to   December   2013,   providing   insights   to   a   broader  stakeholder  buy  in  and  the  conceptual  transition  from  pay  for  performance  to  results  based  financing.  

The  final  and  ongoing  sixth  phase  from  January  2014  to  September  2015  focuses  on  processes   in   place   towards   the   making   of   the   results   based   financing   design   and  defining  early  scale  up  and  financing  plans,   including  emerging  challenges  from  the  Kishapu  pilot;   it   also  examines  alignment  of  other   strategies  and  plans   towards  an  integrated  systems  based  approach.  

Figure   2   presents   a   linear   timeline   of   key   events   in   the   evolution   of   the   RBF   policy   and  programmes.  

   

  30  

Figure  2.    Timeline  of  key  events  in  the  RBF  policy  formulation  process,  November  2006  –September  2015      

     

I&II. 2006-2007 Political momentum & consensus building  • Global network of MDG4 & 5 leaders  

• 1st high level talks between Tz Minister and Norway PMO, Dec 2006

• President of Tanzania and PM of Norway make a political commitment to MN, get it translated into action

• Norway rejoins Health Basket with P4P agenda, Jan 2007

• Norway Tanzania Partnership Initiative, February 2007

• Launch of TPMNCH, April 2007

• Health Basket Fund partners refused to endorse a jointly endorsed P4P system

• Norway establishes the HRITF (2007) to be managed and administered by WB

III. 2007-2009 First national P4P scheme  • P4P Feasibility Study to RNE , Sept 2007  

• P4P Consensus Workshop, Nov 2007

• Final Draft National P4P Design to RNE, Feb 2008

• GoT instructs District Councils to allocate for P4P in 2008/09 CCHP, March 2008

• President Kikwete prioritised MDG 4 & 5 in African Union, Apr 2008

• President Kikwete launches national MNCH roadmap & Deliver Now Advoacy Campaign, April 2008

• Norwegian evaluations and appraisals (March 2008, April 2009

• MoHSW Revised P4P Design/Implementation Plan to HBF Partners, Feb 2009

• GoT unsuccessfully launches 1st National P4P Scheme, Mar 2009

• P4P a priority strategy in HSSPIII (2009-2015)

IV & V. 2010-2013 Pwani P4P pilot & transition to national RBF initiative  

• MoHSW requests RNE for Norwegian support to pilot a revised P4P model, early 2010  

• MoHSW implements P4P Pwani Pilot, Jan 2011

• P4P unit established , 2011

• Musoka G8 Summit, June 2010

• Oct 2011 JAHSR HF a core reform area; MoHSW starts working on a HF strategy

• RNE commissions IHI evaluation of P4P Pilot, August 2011

• Revised P4P design released, Feb 2012

• CORDAID International PBF Conf, Dsm., Mar 2012.

• MoHSW/CHAI participated in a WB RBF regional workshop, Zambia, 2012.

• National P4P Best Practices Meeting , Jan2013

• National Rungwe PBF Pilot Forum, Bagamoyo, June 2013

• Multistakeholder P4P Assessment, WB/USAID/Norway, Apr 2013

• 1st National HRH Conf, Sept 2013

• P4P/ RBF Workshop, Bagamoyo, Nov 2013-MoHSW-WB in the lead

• National RBF Task Force established

• IHI-LSHTM-CMI P4P dissemination, Dec 2013  

VI. 2014-2015 The RBF national design & early scale up plans

• President Kikwete launches Tz Countdown to 2015 & RMNCH Scorecard, May 2014

• President Kikwete attends high level MNCH summit mtg, Canada, May 2014

• President Kikwete launches Sharpened One Plan, Aug 2014

• BRN Health Lab, Sept 2014

• RBF unit established in MoHSW, Feb 2014

• RBF unit established in PMO-RALG

• Final BRN Framework released, Jan 2015

• WB introduces GFF to HF and MNCH TWG, Jan 2015

• BRN Star Rating Initiative, Feb 2015

• Aligning HFS, RBF, BRN & HSSP IV, Mar 2015 onwards

• 2nd GFF Mtg (WB, WHO, UNFPA, Apr 2015

• WB (loan), USAID/USG, GFF, Power for Nutrition funds for 7 BRN regions over 5 yrs, Sept 2015

• Revised performance based Basket MoU with GoT

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3.2.1. Phase  1:  political  momentum  for  MDGs  4  &  5,  2006-­‐2015.    

“    ….the  network  of   global   leaders   in   health  had  an   important   role   to  play  globally  and  from  the  very  beginning  the  President  of  Tanzania  along  with  the  Prime  Minister  of  Norway  were  part  of  that  (the  network)”  [Key  Informant  [KI]  19]  

There  has  been  a  high  level  national  and  global  advocacy  and  political  momentum  for  MDGs  4  and  5  from  2005  onwards.  This  momentum  has  continued  to  this  day,  with  a  number  of  planned  events  that  provided  a  platform  to  highlight  Tanzania's  priorities  for  reproductive,  maternal,   newborn   and   child   health   (RMNCH)   and   her   “growing   interest   in   results   based  financing”.  [KI  19]    

Strong  partnerships  to  address  maternal  health  have  been  established   in  the  process  with  President  Kikwete  of   Tanzania  being  at   the   forefront.   The  Norwegian  Prime  Minister   Jens  Stoltenberg  and  President  Kikwete  co-­‐chaired  the  global  network  of  leaders  of  MDG  4  and  5.  President  Kikwete  raised  the  health  MDGs  high  on  the  agenda,  with  a  particular  focus  on  women   and   children,   nationally   when   he   launched   the  Roadmap   for  Maternal,   Newborn  and  Child  Health  (MNCH)  in  Tanzania  in  April  2008,  as  well  as  regionally  as  a  Chairperson  of  the  African  Union  in  the  same  month.  To  support  the  implementation  of  key  strategies  set  out   in   Tanzania’s   MNCH   roadmap,   in   April   2008,   President   Kikwete   and   the   Norwegian  Prime  Minister  launched  the  global  advocacy  drive  Deliver  Now  for  Women  and  Children  in  Tanzania30:   “it   was   also   when   the   bilateral   agreement   for   health   between   Norway   and  Tanzania  was   signed”.   In   early  May   2014,   as   co-­‐chair   for   the  Commission   on   Information  and  Accountability   for  Women's  and  Children's  Health   (COIA),  President  Kikwete   launched  the   “Countdown   to   2015”31   study   at   a   high   level   event   held   in   Dar   es   Salaam,   Tanzania  (MoHSW  May  2014).  Following  this,  the  President  initiated  the  ‘Sharpened  One  Plan’  (2014-­‐  2015)   to  “build  a  strong  foundation   for  a  strategic  direction  towards  ending  maternal  and  child  mortality  in  post  2015  »32  (MoHSW  April  2014)  and  the  RMNCH  Score  Card  system,  “to  track  progress  of  key  RMNCH  indicators  at  both  national  and  subnational  levels”.  33      

Soon   after,   President   Kikwete   joined   his   fellow   co-­‐chair   of   COIA,   Prime  Minister   Stephen  Harper  of   Canada,   at   a   high-­‐level   summit   in   Toronto,   “Saving  Every  Mother,   Saving  Every  Child:  Within  Arm’s  Reach”.  The  Toronto  summit  followed  the  June  2010-­‐G8  summit  (held  in  Muskoka,  Ontario),  when  Canada  led  G8  and  non-­‐G8  countries  to  commit  Canadian  dollars  7.3bn  (from  2010  to  2015)  to  maternal,  neonatal  and  child  health,  with  Tanzania  as  one  of  the   beneficiaries   of   the   programme.34   In   May   this   year,   the   Canadian   Prime   Minister  announced  the  renewal  of  the  Muskoka  Initiative  for  another  five  years,  as  well  as  stepping  up  Canada’s  contribution  to  MNCH35.  Speaking  at  the  Toronto  summit,  the  President  of  the  World   Bank   Group  made   a   passionate   plea   for   investing   some   of   these   global   resources  towards  “results-­‐oriented  service  delivery”.36    

                                                                                                                         30  http://www.who.int/pmnch/activities/delivernow/en/index4.html  31    http://www.countdown2015mnch.org/countdown-­‐news/50169-­‐tanzanian-­‐countdown-­‐to-­‐2015-­‐launched-­‐will-­‐this-­‐count-­‐for-­‐women-­‐and-­‐children  (funded  by  the  Canadian  government  and  facilitated  by  the  London  School  of  Hygiene  and  Tropical  Medicine,  in  collaboration  with  MoHSW,  WHO  and  Evidence  for  Action  and  other  partners  in  Tanzania)  32  http://countryoffice.unfpa.org/tanzania/2014/08/18/10368/putting_mothers_of_tanzania_first/.    33  http://www.countdown2015mnch.org/documents/tanzania/Countdown_scorecard_-­‐_Tanzania_National.pdf)  34  http://www.thecitizen.co.tz/News/national/Aga-­‐Khan-­‐commends-­‐Canada-­‐on-­‐leadership/-­‐/1840392/2332398/-­‐/avjsvvz/-­‐/index.html  )  35  https://www.devex.com/news/renewed-­‐initiative-­‐shines-­‐spotlight-­‐on-­‐canada-­‐s-­‐deeply-­‐divisive-­‐mnch-­‐approach-­‐84985  36  http://www.worldbank.org/en/news/speech/2014/05/30/speech-­‐world-­‐bank-­‐group-­‐president-­‐mnch-­‐summit  

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Stepping   back,   from   2005   onwards,   the   Norwegian   Prime   Minister   was   emerging   as   a  prominent  player   in  the  global  campaign  for  health  MDGs  4  &  5  -­‐   in  promoting  innovative  financing   mechanisms   globally,   in   particular   after   the   reported   “success   stories”   from  Rwanda  and  Haiti;   in  providing   increasing   financial   support   to   the  United  National,   global  maternal   and   child   health   campaigns   and   global   health   initiatives;   as   well   as   bilateral  support  to  countries  lagging  behind  in  MDG  4  and  5  (Olsen  January  2009).  

“There   was   a   political   momentum   that   was   quite   important   and   with   a   strong  collaboration.  There  was  a  need  to  find  a  good  program  in  Tanzania   in  child  health  initially  and  then  maternal  health…  this  was  because  of  the  overall  figures.  Also  there  was   a   need   to   have   a   country   in   Eastern   Africa   where   there   was   some   kind   of  traditional  Norwegian  development  aid;  as  well  as  a  potential  to  really  get  something  done.  So  Tanzania  was  an  obvious  case  to  focus  on  MDG  4  and  5   initiatives….but   it  basically  came  out  of  the  figures  as  was  also  the  case  in  Nigeria  and  India,  “  [KI  19]  

It   is   within   this   context   when   Norway   was   trying   to   launch   the   global   business   plan   for  maternal  and  child  health  that  preliminary  talks  were  held  between  Tanzania’s  Minister  of  Health  and  the  Norwegian  Prime  Minister’s  Office  in  December  2006,  centered  on  ways  to  address  MDGs  4  and  5  within  a  performance  incentive  framework  (Smithson  et  al.  2007,  p.  2).  Ifakara  Health  Institute’s  executive  director  was  also  present  at  this  meeting.    The  talks  culminated   in   the   signing   of   the   Norway   Tanzania   Partnership   Initiative   (NTPI)   by   the  respective  heads  of  state  during  President  Kikwete’s  visit  to  Norway  in  February  2007,  when  attending  a  meeting  on  the  Global  Business  Plan  for  MDGs  4  and  5  (Morgan  &  Eichler  2009,  p11).  Norway  agreed  to  contribute  approximately  US$32  million  over   five  years   to   reduce  maternal   and   child   mortality   in   Tanzania,   with   Pay   for   Performance   (P4P)   as   one   of   the  strategies  to  be  used  [Morgan  &  Eichler  2009].37  P4P  was  one  of  the  four  components  of  the  bilateral   agreement;   the   other   three   being   support   to   the   health   system   more   broadly  through   the   Health   Basket,   the   Health   Management   and   Information   System   (HMIS)  strengthening   initiative   in   the  MoHSW,   and   support   to   civil   society  organisations   [KI   5,   KI  16].      

Thus,   the  P4P   initiative   “started  with  a  discussion  between  Prime  Minister  of  Norway  and  President  Kikwete  when  they  were  together  the  co-­‐chairs  of  the  global  network  of  leaders  of  MDG   4   and   5.  »   (KI16).   They   wanted   to   make   a   political   commitment   to   maternal   and  neonatal  health  and  get  it  translated  into  action.  It  is  “what  the  president  wanted  and  gave  stokes   and   instructions   for   it   to   happen“   [KI   13].   Ifakara   Health   Institute   (IHI)   executive  director  was  equally  “interested  to  have  Tanzania  as  one  of  the  first  countries  to  introduce  performance  based  models”  [KI  14].  

   

                                                                                                                         37  Since  2007,  Norway  has  advocated  the  use  of  RBF  to  influence  the  behavior  of  states,  organization  and/or  individuals  through  major  initiatives  in  health,  climate  change,  as  well  as  in  clean  energy  since  2011;  and      is  currently  advocating  for  its  use  in  the  education  sector  (Linekvist  &  Bastoe  2015).  

 

  33  

3.2.2 Phase  II:  building  national  consensus  for  pay  for  performance,  2007  

With  support  from  Broad  Branch  Associates  (BBA)  and  the  Ifakara  Health  Institute,  Norway  tried   to   promote   dialogue   and   build   some   consensus   among   Tanzania’s   key   stakeholders  around  the  prospects  of  introducing  P4P  in  Tanzania.  A  first  workshop  held  in  April  2007  in  Dar  es  Salaam,  lead  by  Tore  Godal,  the  special  adviser  to  Norwegian  Prime  Minister,  and  a  consultant   from  BBA,   formed   the  basis   for  a  draft  P4P  program  document   that   set  out   in  more  detail  how  Norway’s  assistance  would  be  manifest,  conditional  on  implementing  the  P4P   intervention  [KI  7,  13,  16].   It  was  P4P  or  nothing.  The  BBA  consultant   ‘was  explaining  how  P4P   is  almost   like  a  cure,  as   sort  of  a  new  modality  of  aid   that  was  going   to  be  very  revolutionary  and  was  going  to  have  some  major  impact’  [KI  7].    

A   second   workshop   was   facilitated   by   a   consultant   from   the   Ifakara   Health   Institute   in  November  2007,  on  behalf  of   the  Norwegian  Embassy  and  USAIDs  Health  Systems  20/20.    This  workshop  discussed  the  experiences  of  various  P4P  initiatives  in  the  country,  including  Cordaid’s   PBF   model.   Participants   were   also   invited   from   Rwanda   to   present   on   the  Rwandan  model.  

Attending   this  workshop  were   representatives   from  the  MoHSW,  other   central  ministries,  the   local   government,   development   partners,   civil   society   organisations   (CSOs),   and   from  the  academia:  “an  open  strategy   to  ensure   that  as  many  development  partners  and  other  agencies  were  involved  as  possible’  [KI19].  This  is  when  health  basket  fund  partners38  were  first   informed  of  Norway’s   and   the   government  of   Tanzania’s   interest   in   introducing  P4P,  and  subsequently  again  during  a  basket  fund  committee  meeting  in  January  2008  [Morgan  &  Eichler  2009].      

The  period  between  2007   and  2009  was   generally   fraught  with   political   tension  between  Norway,  health  basket  fund  partners  and  the  Government  of  Tanzania  (see  Tables  5  and  6).  This  tension  between  key  stakeholders  is  well  documented  by  Morgan  &  Eichler  2009,  p12  and  Chimhutu  et  al,  2015.  

Table   5.   Influence   and   position   of   key   actors   during   Phase   I   and   II   of   the   RBF   policy  formulation   process:   December   2006-­‐mid   2007,   High   level   political   momentum   and  consensus  building  

                                                                                                                         38    Canada,  Denmark,  Germany,  Ireland,  Netherlands,  One  UN,  Switzerland  (Swiss  Development  Corporation-­‐SDC),  UNFPA,  UNICEF,  and  the  World  Bank.    39  H-­‐High;  M-­‐Medium;  L-­‐Low  

SUPPORTIVE NOT MOBILISED/ NEUTRAL

OPPOSED

LEVEL OF INFLUENCE

H M L L M H39

High GoN-PMO (and special advisor), GoT-Presidents Office

HBF (SDC, DANIDA), WB, UNFPA

Medium BBA

Low MOHSW-Dept Planning & Policy, IHI

Norad, RNE-Tz, MoHSW (some), central & line ministries, CSO, researchers

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Table  6.  Phase  I  and  II:  Facilitators  and  Barriers  

Facilitators     Barriers  Key  Actors   Key  Actors  • Strong  partnership  between  President  Kikwete  

and  Prime  Minister  of  Norway  (and  technical  adviser);  and  their  commitment  to  addressing  MDG  4  and  5.  

• Support  from  MoHSW,  IHI,  Broad  Branch  Associates  

 

• NORAD  not  able  to  move  the  P4P  agenda  as  anticipated/planned/hoped  

• Reluctance  among  most  health  development  partner’s  to  endorse  P4P  –  concerns  with  capacity  &  weaknesses  of  the  health  system,  lack  of  P4P  evidence,  &  distrust  (discussions  with  Norway  on  a  such  a  huge  reform  should  have  happened  much  earlier)  –  resulting  in  lack  of  consensus  between  Norway  &  health  basket  fund  partners  

• Different  priorities  between  the  Head  Quarters  in  Norway  and  the  Norwegian  embassy  in  Dar  es  Salaam  given  their  earlier  strategic  withdrawal  from  the  health  sector    

Context   Context  • MDG  4&5  political  momentum  at  global,  regional  

and  national  levels  with  President  Kikwete  at  forefront  

• Growing  Norwegian  interest  and  funds  for  addressing  MNCH  through  innovative  financing  (RBF),  bilateral  and  through  World  Bank  managed  HRITF  

• Weak  national  health  systems  and  poor  quality  of  services,  high  maternal  mortality  ratio  

• Tanzania  beneficiary  of  MNCH  funds;  bilateral  agreement  with  Norway  

• Norway  in  discussion  with  Health  Basket  fund  partners  to  channel  P4P  and  other  ‘unearmarked’  funds  to  the  health  sector  through  the  Basket,  provided  the  P4P  was  jointly  endorsed  which  did  not  work  out  (eventually  entered  a  separate  bilateral  arrangement  funding  preparation  for  P4P)  

• Norwegian  bilateral  agreement  time  bound  and  conditioned  on  introduction  of  P4P  

• Norwegian  embassy  (Dar  es  salaam)-­‐  inadequate  capacity  and  resources  to  support  the  P4P  process  (had  exited  from  the  health  sector)  

 

Processes   Processes  • Several  related  initiatives,  strategies,  plans  

launched    

 

According  to  one  key  informant  [KI19],  there  was  “a  lot  of  reluctance  among  different  development  partners  for  different  reasons”:  DANIDA  was  opposed  to  what  they  thought  was  “a  market  type  of  mechanism”;  others  believed  that    “it  was  not  the  direction  the  Tanzania  government  wanted  to  move  towards,  or  they  didn’t  think  they  [MoHSW]  had  the  

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[technical]  capacity  and  so  on”;  and  the  Swiss,  the  World  Bank  and  United  Nations  Family  Planning  Association  (UNFPA)  had  their  concerns.  Generally,  most  HBF  partners  ‘felt  left  out  and  this  was  something  too  big  for  them  not  to  have  any  stake  in’;  and  they    “wanted  to  decide  over  the  funds  that  they  configured  with;  whereas  the  government  said  that  it’s  their  policies  that  counted  and  that  they  wanted  to  do  it  in  their  way,”  [KI  19].  USAID  was  supportive  but  was  “not  really  able  to  co-­‐fund  into  the  common  mechanism  and  also  wanted  to  see  how  this  went  before  they  co-­‐funded  directly”  [KI  19].   However,   according   to   another   key   informant   [KI   21],   the   concern   of   some  of   the   health  basket  fund  partners  was  more  to  do  with  the  hurried  manner  in  which  a  potentially  “huge  reform”   was   being   introduced   in   a   “project   like   manner”,   especially   given   capacity  constraints  and  shortcomings  in  the  performance  of  the  systems;  technically  unsound  and  a  “missed  opportunity”;   the   “biggest”  problem  was   that   the initiative was being “politically rather than technically re-driven….  Tanzania  is  not  Rwanda....  are  we  really  buying  services  instead  of  pre-­‐financing  it?”  [KI  21].  

There   is   limited   information   on   if   there   was   consensus   among   national   stakeholders,   in  particular  within  the  MoHSW  and  within  central  and  line  ministries.    

There  was  a  level  of  distrust.  Health  basket  fund  partners  felt  that  Norway  was  manipulating  the  Basket  to  advance  on  their  own  agenda  (Morgan  &  Eichler  2009,  p12  and  Chimhutu  et  al,  2015).  Norway  was  a  formative  member  of  the  Health  Basket  in  1999,  and  had  decided  to  exit  the  Basket  and  support  to  Tanzania’s  health  sector  in  2004  as  health  was  not  seen  as  their   comparative   advantage   (a   political   decision   and   part   of   the   Aid   effectiveness  discussion  that  was  going  on   in  early  2000).   In  2007  Norway  decided  to  re-­‐join  the  health  basket  with   the  P4P  agenda.  The  Norwegian  embassy   in  Dares  Salaam  was  being  dragged  back   into   the   health   sector   by   decree,   in   direct   contradiction   to   their   earlier   strategic  withdrawal   and   without   the   resources   to   manage   it:   they   were   ‘‘forced   to   implement  something   that   they   didn’t   agree  with;   to   get   involved   in   a   sector   that   they   had   already  decided  to  exit  from’,  [KI  7].    

Norway  tried  to  reach  a  compromise  with  HBF40  partners  towards  an  agreement  to  channel  80%  of  the  funds  through  the  Basket,  part  of  which  could  be  used  for  the  implementation  of  a   P4P   system,   provided   it   was   jointly   endorsed.   However,   this   did   not   happen.   Norway  channeled  funds  to  the  health  sector  through  the  Basket  to  support  “activities/components  (unearmarked)  that  were  seen  to  be  highly  relevant  for  any  future  P4P  as  well  as  for  service  provision   improvements   more   in   general’,   (KI9).   Separate   bilateral   funding   arrangements  were  made  for  the  P4P  (see  following  section  3.2.3).  The  remaining  20%  were  set  aside  for  strengthening   the   Health   Management   Information   System   (HMIS)   and   Monitoring   and  Evaluation.    

Norway’s  support  “made  a  huge  difference  to  the  health  basket  fund  because  it  was  like  one  fourth  of  the  fund”    [KI  19].      

                                                                                                                         40  The  Health  Basket  Fund  is  a  flexible  fund  that  is  used  by  Council  Health  Management  Teams  and  Regional  Health  Management  Teams  to  address  the  needs  of  their  communities.  Health  Basket  funds  are  regularly  used  to:  purchase  essential  medicines  and  equipment;  implement  community  outreach  programmes;  conduct  health  promotion  activities;  maintain  equipment,  facilities  and  vehicles;  provide  sanitation  and  waste  facilities;  and  provide  electricity  and  water  to  health  facilities.  Since  its  inception  in  1999/2000,  health  basket  fund  partners  have  provided  over  US$  950m  towards  improving  primary  health  care  services  in  Tanzania.  

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3.2.3 Phase  III:  the  first  national  pay  for  performance  scheme,  2007-­‐2009  

The  first  draft  P4P  design  for  Tanzania  was  pulled  together  by  a  IHI  consultant  in  May  2007  when  attending  the  first  international  P4P  workshop  in  Kigali,  Rwanda,  that  was  sponsored  by  USAID  funded  health  systems  2020  project  (Morgan  &  Eichler  2009,  p13).  Subsequently  the  IHI  consultant  was  commissioned  by  Norad  to  conduct  a  more  in-­‐depth  feasibility  study  addressing   the   practical   modalities   of   a   P4P   system.   The   report   on   ‘Feasibility   and  Implementation   Options’   was   released   in   September   2007,   recommending   a   phased  implementation   of   the   P4P   initiative,   emphasizing   certain   preconditions   including,  strengthening   the   Health   Management   Information   System   (Smithson   et   al   2007).   Key  design  considerations   included:  accelerating  progress  towards  MDG  4  and  5;  working  with  and   through   government   systems   and   structures,   using   joint   financing   mechanisms;  channeling   resources   towards   front-­‐line   essential   services;   increased   emphasis   on  accountability   for   enhanced   performance;   and   exploring   the   potential   application   of  “performance-­‐based  financing”  in  the  Tanzania  context.  

Around  the  same  time,  the  Chr.  Michelsen  Institute  (CMI),  a  Norwegian  research  institution,  carried   out   a   study   to   assess   the   potential   of   introducing   performance   based   financing  towards  reducing  maternal  and  neonatal  mortality  Tanzania.  The  study  provided  a  number  of  arguments   for  and  against  P4P.   It  noted  that   the  present  system,  where  “districts  have  responsibility  for  the  development  of  health  plans,  but  where  their  autonomy  in  the  budget  allocation  process   is   restricted  by  a  wide   set  of   regulations  and  where   there   is   little  or  no  accountability  for  results,  is  also  far  from  ideal”  –  essentially  reaffirming  the  need  for  facility  level  financial  autonomy  (Mæstad  2007,  p.  30,  quoted  in  Morgan  &  Eichler  p13).  The  study  went   on   to   conclude   that:   “Performance-­‐based   funding   at   the   district   level   is   not   in   itself  sufficient  to  achieve  the  desired  effect  on  maternal  and  neonatal  health.  The  scheme  needs  to  be  complemented  by  broader  national  efforts  to  strengthen  the  health  system”.  (Maestad  2007,  p30)”  

The  IHI  consultant  was  then  commissioned  by  the  Royal  Norwegian  Embassy  (RNE)  in  Dar  es  Salaam   to   coordinate,   lead   and   facilitate   the   design   process   on   behalf   of  MoHSW.   There  followed  an   intensive  design  process   -­‐   a   team  effort,   including  active  participation  of  one  regional  and  one  district  medical  officer,  as  well  as  a  CORDAID41  representative.  The  process  was   technically   supported   by   a   consultant   from  BBA   (directly   contracted   by   IHI),   and   the  Norad  technical  adviser.  

‘So  I  was  then  tasked  to  design  this  program  in  more  detail.  We  were  a  small  team  and  we  went   around   talking   to   different   districts   and   health   care   providers,   policy  makers  and  program  managers  on  how  this  should  be  designed.  We  came  up  with  a  rough  design  which  was  then  discussed.’  (IHI  consultant)  

The   draft   design   received   some   support   from   the   health   basket   funders,   but   with   some  concerns  which  centered  around  the  estimated  US$  1  million  budget  that  would  be  needed  to  sensitise  all  the  district   level  managers  and  facility   level  staff  to  the  Scheme  (Morgan  &  Eichler  2009,  p14)[KI  7,  14].  The  drafting  team  was  ‘pressured  to  find  a  cheaper  way’  [KI  14].    

                                                                                                                         41  Note  that  at  the  time  the  CORDAID  model  was  not  the  same  as  the  PBF  model  they  advocate  today.  

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In  mid-­‐February   2008   a   final   draft   on   "Results   Based   Bonus:   Design,   Implementation   and  Budget"   was   submitted   by   the   IHI   consultant   (on   behalf   of   the   drafting   team)   to   the  Norwegian   Embassy,   recommending   a   phased   implementation   of   the   Scheme   starting   in  July   2008,   but   contingent   on   prior   strengthening   of   the   HMIS;   the   approach   was   to   be  continuously   refined  along  the  way  –  a   learning  by  doing  approach   (Smithson  et  al  2008).  The  making   of   the   first   P4P  model  was   reportedly   a   rushed   process,   trying   to   get   all   the  essentials   done   (design,   training   materials   and   the   trainings)   with   the   intention   of  synchronising  the  implementation  of  the  national  scheme  with  the  government  fiscal  cycle  [KI  14].  

Available   evidence   suggests   that   Broad   Branch   Associates,   Ifakara   Health   Institute   and  Norad  were  the  three  key  partners   really  driving   the  process   forward  at   this   first  national  design  stage.  The  government  was  “already  as  involved  as  they  should  be  in  terms  of  it  being  identified   as   a   project”,   according   to   one   key   informant;   they   were   “part   of   the   team  designing  it….  and  also  had  identified  a  unit  in  the  ministry  that  would  be  responsible  for  it  at  that  stage”  [KI  19].  

The  MoHSW  disagreed  with   the   IHI   design  on   the  basis   that   it  was   ‘too   complicated’.  On  behalf  of  MoHSW,  Norway  then  hired  a  team  of  (Tanzanian)  consultants  to  redo  the  design  with  MoHSW.  The  Tanzanian  team  participated  in  a  multi-­‐country  World  Bank  workshop  in  Rwanda   around   October   2008   and   they   went   through   a   redesign   process.   This   revision  process   was   essentially   driven   by   the   team,   including   an   IHI   consultant   and   a   USAID  representative  [KI  14].  

The  first  national  design  appears  to  have  been  somewhat  influenced  by  the  Rwanda  model.    

“….we   had   these   workshops…we   would   visit   Rwanda   and   they   would   break   up   in  groups.  Everyone  would  go  to  speak  to  people  in  facilities  who  told  everybody  what  they   did   differently   and   I   think   that   it   was   very   compelling   in   the   workshops   for  people  to  see  it  on  the  ground…kind  of  an  anecdotal  type  of  evidence.  Back  in  those  days  we  didn’t  have  the  results  of  the  evaluation  from  Rwanda.”  [KI  14]    

In  February  2009,  MoHSW  presented   its  own  national  P4P  design   (MoHSW  Dec  2008a),  a  highly   simplified   version  of   the   Ifakara  design;   and  an   implementation   guideline   (MoHSW  Dec  2008b)  at  a  health  basket  fund  partners  committee  meeting.42  They  “changed  some  of  the   indicators   and   the   triggers   for   payment   and   the   way   which   the   payment   should   be  allocated”  [KI  7].    

The  health  basket  fund  partners  refused  to  fund  the  national  P4P  programme  through  the  basket  until   the  MoHSW  plan  was   further   revised.   .   The  design  was   regarded  by  many  as  “not  feasible,  too  expensive  [huge  roll  out  trainings  and  incentives],  too  slow  and  risk-­‐prone”  [KI   7].   Health   basket   fund   partners   had   several   concerns   relating   to   the  weakness   of   the  existing   health   information   system   and   the   choice   and   effectiveness   of   the   selected  performance  indicators,  but  it  mainly  boiled  down  to  a  weak  verification  system  -­‐  payment  on  data   that  are  not   independently  verified   [KIs  2,  3,  5,  14,  6,  13].  They  also   felt   that   the  design   should   first   “be   piloted   somewhere”   before   going   nationwide   to   first   get   a   better  understanding   its   feasibility  and   implementation  challenges  and   learn   from  the  challenges  (KI  19,  KI  21).  P4P  “was  a  huge  reform  and  not  an   isolated  project,  and  an  opportunity   to  

                                                                                                                         42  Basket  Fund  Committee  meeting  held  on  February  19th,  2009.  

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learn  on  how  to  make  this  reform  a  success”  [KI  SDC].  It  has  also  been  reported  that  health  basket   funders  “resented  a  challenge  to  their  power/authority  and  tried  to  veto   it”   [KI  7].  The  USAID  was  also  concerned  [KI  13]  and  eventually  stepped  in  and  became  involved  in  the  P4P  pilot  phase,  by  supporting  Broad  Branch  Associates  to  technically  assist  with  designing  the  P4P  Pilot  scheme  which  followed  much  later  on  in  2010-­‐11.  

Norad   then   commissioned   an   independent   technical   appraisal   of   the   government’s   P4P  plan.  The  appraisal  concluded  that  the  national  programme  should  not  go  ahead  unless  the  routine   information   system   was   strengthened,   and   unless   there   is   a   mechanism   for  independent  verification  [KI  7]  (Morgan  &  Eichler  2009,  p14).      

Eventually,   all   health  development  partners   -­‐  health  basket   fund  partners,   the  USAID  and  Norway  –  were  of  the  opinion  that  a  major  reform  as  such  needed  to  be  piloted  first  (see  Table  7).      

Based   on   a   principle   of   not   doing  more   pilots,   the  MoHSW   rejected   the   idea   of   a   pilot,  wanted  the  national  P4P  scheme  to  go  to  scale  and  for  all  districts  to  be  treated  equally.  The  President  (and  therefore  the  MoHSW)  really  wanted  to  implement  the  national  programme  [KIs  7,  13,  14,  16,  19].  The  MOHSW  was  under  huge  pressure  to  go  ahead  with  the  national  P4P   scheme   at   any   cost,   to   show   that   something   is   being   done   in   order   to   access   the  Norwegian   funds,  but  were  being  blocked  by  basket  partners   [KI  7].    Also,   it  was   clear   to  MoHSW   that   “there   was   a   need   to   change   how   it   funds   services”   because   the   existing  system  was   “not   working”.   The   government   was   “partly   looking   towards   Rwanda   saying  that  they  had  managed  to  do  a  lot  within  quite  a  short  time;  and  so  they  can  do  it  as  well”  [KI  19].  And  so  in  one  basket  committee  meeting,  the  Permanent  Secretary  (from  MoHSW)  finally  remarked  “okay  if  you  partners  are  not  going  to  support  us  we  are  going  to  do  it;  we  will  secure  funds  from  elsewhere.…..…”  [KI  6].  GOT  essentially  told  the  basket  partners  that  they  would  go  ahead  and  do  what  they  want  to  do  in  spite  of  basket  partner  concerns.    

The  P4P  concept  had  been  incorporated  in  third  Health  Sector  Strategic  Plan  (2009-­‐  2015)  as  a  P4P  strategy  to  enhance  the  productivity  and  motivation  of  health  care  workers   [KI  16].  District   councils  had  already   received  an  official   circular   (dated  March  18,  2008)   from  the  directorate  of  planning   in  the  MoHSW  instructing  them  to  formally   include  an  P4P  budget  line   in   their   2008/09  Comprehensive  Council  Health  Plan   (CCHP)   (Morgan  &  Eichler  2009,  p24).    

Thus   shortly   after   March   2009,   the   Government   of   Tanzania   gave   a   directive   for   the  implementation   of   the   P4P   scheme   in   all   districts   without   really   fully   working   out   the  operational   processes,   and   without   the   endorsement   of   the   country’s   health   sector  development  partners,  including  Norway  [KIs  2,  3,  6b,  13,14,  16,  19].  The  health  basket  fund  partners  had  meanwhile  decided  for  the  share  of  district  basket  grant  set  aside  by  Councils  for   bonuses   as   well   as   the   basket   funds   already   released   under   P4P   for   2008/09   to   be  reallocated  and  used  for  the  procurement  of  medicines  and  supplies  or  be  transferred  as  a  balance  for  FY  2009/10  (Morgan  &  Eichler  2009,  p14).  43    

 

                                                                                                                         43  Note:  Health  Basket  Funds  (HBFs)  are  unrestricted  funds  to  support  activities  that  are  in  the  CCHP,  but  since  the  CCHP  guidelines  had  included  P4P,  the  Councils  had  included  P4P  in  their  CCHPs.  After  the  HBF  decided  not  to  endorse  the  national  P4P  design,  the  basket  funds  could  not  be  used  for  paying  P4P  bonuses.  The  P4P  budget  line  item  remained  in  the  plans  but  could  not  be  funded  with  funds  from  HBF;  but  other  sources  were  allowed.  

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Table  7.   Influence  and  position  of  key  actors  with  respect   to   the  RBF  policy   formulation  process  from  2007  -­‐2009,  designing  the  first  national  P4P  Scheme.  

Note:  H-­‐High,  M-­‐Medium,  L-­‐Low  

 

The   first   national   programme   was   short   lived   and   unsuccessfully   implemented.   Some  districts  apparently  did  start  to  make  some  initial  plans  for  it,  some  were  trained  and  a  few  started  to  try  to  implement  it.  The  research  team  failed  to  access  information  on  how  many  districts  actually  implemented  the  scheme  and  for  how  long,  and  if  any  are  still  continuing  to  do  so.  

The  decision  to  go  national  right  away  was  controversial  (see  Table  8).    A  number  of  factors  probably  resulted  in  its  unsuccessful  implementation  –  no  funds,  challenges  with  the  design,  limited  understanding  of  the  concept  at  all   levels  of  the  system  with  no  prior  preparations  (i.e.   no   training  on  how   to   implement,   no   contracts,   no   verification   system   in  place),   and  inadequate  technical,  implementation  and  financial  arrangements  [KIs  2,6,7].  Districts  were  simply  provided  with  a  copy  of  IHI’s  Results  Based  Bonus  Report  and  "Annex  3  Background  Information   for   Design   Parameters”,   which   was   ‘was   a   consultancy   report,   and   not   a  guideline’  [KI  7]:  “there  were  a  lot  of  queries  and  a  lot  of  confusion”  [KI  2].  

   

SUPPORTIVE NOT MOBILISED/ NEUTRAL

OPPOSED

LEVEL OF INFLUENCE

H M L L M H

High GoT-Presidents Office,

GoN-PMO

World Bank (Tz) HBF (DANIDA, SDC, Irish Aid)

Norad, USAID (towards the end)

Medium Norad & USAID (via BBA) (except towards the end), MOHSW-Dept. Planning & Policy

Norwegian consultants, CMI

Low IHI, CORDAID

Norwegian Embassy,

Health care providers and their managers (some)

P O W E R/I N F L U E N C

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Table  8.  Phase  III  –  Facilitators  and  Barriers  

Facilitators   Barriers  Key  Actors   Key  Actors  • Government  of  Tanzania  (&  

MoHSW)  committed  to  implementing  the  first  national  programme  

• Technical  support  from  IHI,  Norad,  Broad  Branch  Associates,  Cordaid    

 

• MoHSW  did  not  agree  to  first  2007  IHI  coordinated  national  design  (on  behalf  of  MoHSW)  and  suggested  approach  

• HBF  partners  reluctant  to  fund  P4P  out  of  health  basket  due  to  concerns  with  the  national  design  &  system  constraints  

• All  partners  –  HBF,  USAID,  Norad  –  wanted  MoHSW  to  pilot  the  model;  MoHSW  disagreed  to  a  Pilot  

• Health  providers  and  their  managers  at  district  level  not  adequately  prepared/  trained/  supported  to  begin  implementation  process  

Context   Context  • Growing  national  commitment  

&  political  momentum  towards  pulling  together  a  national  design  

• P4P  concept  incorporated  in  HSSP  III  

 

• Health  sector  dependent  on  external  support  • MoHSW  under  pressure  to  effect  the  time  bound  

bilateral  Norwegian  agreement  and  implement  the  national  P4P  programme  

• Basket  funds  towards  P4P  reallocated  to  purchasing  drugs  and  supplies  

• Weak  technical  capacity,  weak  health  systems,  weak  routine  information  systems,  inadequate  funds,  parallel  initiatives,  fragmented  financing  and  increasing  out  of  pocket  expenditures  

• Facility  level  (limited  financial  decision  making  powers)  • Implementation  challenges,  no  funds,  no  technical  

support,  no  training,  absence  of  verification  systems,  limited  awareness,  districts  inadequately  informed  or  sensitised  to  the  P4P  programme  

Content   Content  • An  alternative  approach  to  

fund  facilities  and  address  bottlenecks  

• Potentially  high  training  and  sensitisation  costs    • Weaknesses  in  MoH  design  (choice  of  indicators,  

absence  of  independent),  verification  processes  Processes   Processes  • Design  process:  feasibility  

assessment,  “ownership”  phase  

• District  health  councils  formally  instructed  to  prepare  and  plan  for  P4P    

• Rushed  process  for  introducing  a  huge  reform:  inadequate  preparation  at  central,  local  government  and  facility  level  (understanding  of  the  Scheme  and  the  implementation  process)  

• Absence  of  clear  implementation  and  operational  guidelines  

 

The  Comprehensive  Council  Health  Plans   continue   to   include  a  P4P  budget   line   item   that  was   introduced  with  the   first  national  P4P  scheme.  A  review  of  each  annual  health  sector  review  from  2007  onwards  suggests  a  fairly  regular  discussion  of  P4P.  In  the  guidance  there  are  the  indicators  from  the  original  design  and  the  payments  that  should  be  budgeted  for,  but   then   the  section  of   field  visits   reveals   that  very   few  districts  are   implementing  and  of  

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those  few  districts  implementing,  there  was  no  discussion  about  validation  of  results  [KI  5,  13].  44  

‘..my  impression  is  that  the  government  really  wanted  this  and  that  the  development  partners  did  not  want  it….  I  think  that  they  (DPs)  went  too  far  in  not  supporting  the  government  in  what  the  government  wanted,’  [KI  19].  

Norway’s   P4P   initiative   “was   too   fast…we   didn’t   allow   time   for   the   Tanzanian  Government,   for   the   colleagues   in   the  Ministry   to   really  analyse  and  decide   if   they  are  ready;  if  they  [MoHSW]  are  being  too  ambitious  or  less  ambitious;  it  was  again  a  donor  pushing  something,”  [KI  21].  

 

There  followed  strained  relations  between  health  basket  fund  partners  and  Norad  (and  the  Norwegian   Embassy),   and   with   the   Ministry   of   Health   and   Social   Welfare;   and   between  Norad   and   the  Norwegian   Prime  Minister’s   office   (see   Table   7).   The  Norwegian   embassy  was   not   prepared   for   P4P   having   just   recently  withdrawn   from   the   Sector   –   they   had   no  technical   staff   to   support   this   initiative,   and   found   themselves   under   high   level   pressure  from  Norwegian  Prime  Ministers  office  to  make  it  happen.  The  development  partners  were  divided  amongst  themselves  for  various  reasons  and  some  of  their  concerns  are  reflected  in  Table  5  above.  There  followed  much  confusion  in  the  districts.    

The  overwhelming   feeling   is   that  disagreements  between   the  health  donors  and  between  Health  Basket  Fund  partners  and  the  Government  of  Tanzania  could  have  been  avoided   if  there  had  been  a  discussion  amongst  all  stakeholders  at  the  outset:  “the  quality  (or  rather  the   lack   of)   interaction   and   policy   dialogue,   both   in   terms   of   avenues   available   and  perceptions  of   those  spaces,   to   resolve  some  of   the   (possibly  very  valid)  concerns  partners  may  have  had  at  the  time,”  [KI  9].  

   

                                                                                                                         44  When  the  Pwani  Pilot  was  introduced  in  January  2011,  only  Pwani  used  the  new  P4P  design;  others  continued  as  before  and  no  instructions  were  given  to  stop  the  previous  practice  [KI  5].  

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3.2.4 Phase  IV:  Pwani  pay  for  performance  pilot,  2010-­‐2013  

‘There  was   so  much   reluctance   there   [referring   to  HBF  partners],   that   it   became  quite  difficult  and  that’s  when  [Norway]  focused  on  a  way  of  doing  it  [the  Pilot]  anyway  ….  it  was  framed  as  if  the  pilot  was  to  inform  the  ongoing  national  program,”  [KI  19].  

The  Royal  Norwegian  Embassy  in  Dar  es  Salaam  was  under  immense  pressure  from  Norway  to   spend   all   the   maternal,   neonatal   and   child   health   money   that   had   been   committed  through   the   time   bound   partnership   agreement   with   Tanzania,   and   which   had   to   be  performance  based  –  and  with  no  programme  to  support.  Tanzania’s  MoHSW  was  equally  under  pressure  to  deliver  and  had  to  quickly  respond  to  and  address  concerns  raised  before  the  partnership  funds  came  to  an  end.  The  MoHSW  also  realised  that  ‘they  needed  a  pilot’,  following   the   confusion   they   had   precipitated   in   the   districts   with   the   national   RBF  programme   that   never   really   took   off.   Thus   in   early   2010,   the   MoHSW   made   a   formal  request  to  the  Norwegian  Embassy  (and  Norad)  for  support  from  Norway  to  pilot  a  revised  P4P  model   in   the  Pwani   region  with   the  aim  of   informing  how  to  strengthen  this  national  model   and   to   generate   evidence   on   its   impact.   To   note   that   the   just   launched   national  programme  “was  still  going  on;   it  was  never   stopped…they   [Councils]   could  use  any  other  funds  for  it  [national  P4P],  except  for  the  basket  funds»,  [KI16].  

Meanwhile,  the  Norwegian  Embassy  had  commissioned  IHI  to  undertake  a  scoping  study  on  "Informing   the   Design   of   a   P4P   Initiative   Pilot"   [Kabadi   et   al   2010].   Two   districts   from  Mtwara  region  and  two  districts  from  Pwani  region  were  recommended  for  piloting  the  P4P  initiative.  Pwani  region  was  selected.  Data  from  Pwani  were  expected  to  be  of  higher  quality  than   in  other  regions  as  Pwani  region  had  also  been  designated  as  the  test   region  for   the  HMIS  project  roll  out,  including  testing  of  HMIS  revised  data  collection  tools,  improvement  of  indicators  in  the  District  Health  Information  System  (DHIS)  software,  etc.    

Because  of   the   initial  difficulties  encountered   in   funding   it   through   the  Basket,  Norway   in  consultation   with   MoHSW   decided   to   fund   it   as   a   project   directly,   contracting   and  channeling  the  funds  through  the  Clinton  Health  Access  Initiative  (CHAI)  to  provide  technical  assistance  and  management  support:  “to  support  the  design,  implementation,  to  house  the  pilot  management  team  and  to  support  the  regions  in  implementing  the  design,”  [KI  5].  The  USAID   contracted   Broad   Branch   Associates   to   technically   facilitate   the   design   process   for  Pwani,   using   the  2008  design  document  as   a   resource  document  and  addressing   some  of  the  earlier  shortfalls,  such  as  the  verification  system    [KI  5].    

CHAI  was  the  preferred  choice   for  a  number  of   reasons,   including:   the  Executive  Director,  who  made  it  all  “happen”  [KI  13];  an  existing  good  working  relationship  between  CHAI  and  Norway,   as   well   as   between   CHAI   and   the   government   [KIs   16,   19];   and   the   fact   that  available   funds   could   only   be   diverted   to   P4P   via   a   non   governmental   organisation   as  Norwegian   support   to   the   government   had   already   been   committed   to   the   Health  Management   Information   System   strengthening   initiative   which   CHAI   was   reportedly  supporting  (and  so  an  existing  partnership  was  already  in  place)  [KI  13,  19].  

Thus   in   January   2011,   the   Ministry   of   Health   and   Social   Welfare   with   support   from   the  Clinton   Health   Access   Initiative   launched   a   Pay   for   Performance   pilot   in   Pwani   region   of  Tanzania   to   inform   a   national   programme   (MoHSW   2011).   The   Pilot   was   funded   by   the  Norwegian  Ministry  of  Foreign  Affairs.  The  P4P  initiative  is  implemented  in  all  seven  districts  within  the  Pwani  region,  covering  an  estimated  population  of  just  over  one  million.  All  the  

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public,   private   and   faith   based   206   facilities   (7   hospitals,   17   health   centers,   182  dispensaries)  from  all  the  seven  districts  of  Pwani  region  were  eligible  to  enroll  in  the  pilot  scheme,  on  the  condition  that  they  provide  reproductive  and  child  health  services      Facilities  were  also  required  to  provide  full  2010  Health  Management  Information  System  data,  and  have   bank   accounts   in   order   to   qualify   for   participation.   See   Table   13   for   key   design  features.  

Even  though  preparations   for   implementation  were  underway   in   January  2011,   it  was  not  till  April  2011  when  Norway  confirmed  its  support  for  funding  the  Pilot  and  in  August  2011  signed  an  implementation  contract  with  CHAI:  “CHAI’s  (contract)  was  signed  in  August  and  expenses  from  April  were  accepted,”  [KI  16].  

a. Finalising  the  P4P  pilot  design  

The  making  of  the  first  P4P  pilot  design  was  ‘a  group  process’  including  representation  from  the  regional  and  district  management  team,  as  well  as  from  an  NGO.  The  government  was  also   ‘very  much   involved   in  approving  the  model...  but  xxxxx  was  definitely  by  then  one  of  the  key  drivers,”  [KI  14].  It  was  also  a  rushed  process,  a  “learning  by  doing  approach”,  due  to  the  time  constraints  mentioned  earlier  [KI  13].    

“We  were  constantly  experimenting,  trying  indicators,  removing  indicators,  changing  the  way  that  we  evaluated  indicators;  but  what  we  had  to  keep  at  the  fore  front  for  effectiveness,  we  had  to  convince  the  districts   in  Pwani  that  their  performances  will  be   accurately   evaluated   on  whatever   the   agreement  was   and   that   their   quality   of  performance  would  be  paid,.  “  [ex-­‐P4P  manager].  

A  revised  P4P  design  version  addressing   implementation  challenges   faced   in   two  cycles  of  implementation   was   released   in   February   2012   (MoHSW   2012).     The   P4P   design   was  “stronger   than   the  one  of   the  government   [first  national  design],  …but   it  was  narrower   in  that   it   focused   only   in  maternal   and   child   health”   [KI   5].   The   design   did   not   have   a   total  separation   of   functions   in   its   institutional   structure;   it   is   difficult   to   differentiate   in   the  government  –  for  example,  between  MoHSW  and  PMORALG,  as  “they  are  still   in  the  same  government”;  or  at  the  delivery  system,  where  “the  council  and  facilities  are  one  and  getting  a  separate  purchaser  is  difficult”,  [KI  5].  

Around   the   same   time,   the   P4P   Pilot   Management   Team   shared   a   draft   of     "National  Expansion  of  P4P  Pilot"  (MoHSW  August  2012).    

A  P4P  unit  headed  by  a  P4P  coordinator  and  supported  by  a  deputy  coordinator  and  a  CHAI  staff  member  who  was  seconded  to   the  MoHSW  was  established   in  MoHSW  in  2011.  The  Pilot  Management  Team  (PMT)  set  up  to  oversee  the  implementation  process,  was  chaired  by  the  Government  of  Tanzania  with  a  CHAI  P4P  Programme  Manager  and  a  MoHSW  P4P  Coordinator,   and   homed   in   CHAI   till   recently.   Structures   were   created   to   facilitate  communication  within  the  MoHSW  as  well  as  other  key  partners.  The  advisory  committee  which  incorporated  other  development  partners  and  elements  of  civil  society  was  expected  to  review  and  advise  the  pilot  management  team  on  technical   issues  on  a  quarterly  basis,  but  was  not  very  effective.  All  decision  making  powers  resided  with  the  steering  committee  composed  only  of  the  representatives  from  the  Norwegian  Embassy,  Ministry  of  Health  and  Social  Welfare  and  CHAI.  These  structures  were  not  very  effective  (IHI  June  2012).  

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Norway   was   “the   main   decision   maker   on   financing…this   is   because   the   finances  were  with  Norway   and  we   didn’t   know   how  much   goes   to   supervision,   how  much  goes  to  what  else,”  [MoHSW  representative].  

‘The   government   was   ‘a   responsible   partner….this   has   been   high   on   their   priority  throughout…their   involvement   has   been   very   strong   also   in   the   implementation   of  the  pilot’  [Norwegian  representative].    

Opinions  are  divided  amongst  interviewed  stakeholders.  Some  were  of  the  opinion  that  the  Pilot  was  donor  driven,   implemented  mainly  by  CHAI  with   inadequate   involvement  of  key  stakeholders  from  relevant  departments  within  the  MoHSW,  such  as  the  Reproductive  and  Child   Health   department   or   the   directorate   of   curative   services   [KIs   1,2],   and   with  implementation  funds  managed  and  overseen  by  CHAI  and  “coming  from  outside  the  main  funders   of   health   care   services   (basket   funds)”   [KIs   1,2]   (IHI   June   2013).   A   couple   of   key  informants   believed   that   it   was   not   donor   driven   but   rather   donor   dependent   and   the  MoHSW  was  “very  closely”  involved  in  the  Pilot    [KIs  5,  13,  16].  The  MoHSW  exercised  their  authority  in  the  implementation  process  by  taking  the  lead  in  meetings  with  RHMT,  CHMTs,  and   facility   teams,  noted  one   key   informant   [KI   13].  Also,   in   theory,   the  MoHSW  had   the  power  to  block  or  veto  any  elements  of  the  design  and  had  primary  authority  in  the  amount  of  funds  that  were  payable  through  the  P4P  system  i.e.  the  main  decision  maker  in  deciding  the  funding  levels  for  facilities  by  type,  for  staff,  and  for  management  teams.  (KI  13].    

The  Director  of  Gynecology  at  Muhimbili  Hospital  with  all   the  benefits   that  go  along  with  the  position,  was  moved  and  appointed  as  the  P4P  coordinator  to  partner  with  the  CHAI  P4P  manager   [an   expatriate].     Even   though   her   role   provided   the   technical   authority   of   the  ministry,  without  an  independent  source  of  financial  resources  from  Norway  or  through  the  Ministry   of   Finance,   and   with   limited   authority   in   the   use   of   CHAI’s   funds   for   P4P  management   and   operations   of   the   implementation   process,   she   had   limited   financial  powers  to  back  up  her  decisions.  

There  was  lack  of  clarity  and  tension  in  the  P4P  structure  within  the  MoHSW  –  between  the  RCH   department,   the   national   P4P   program,   and   the   P4P   pilot   –   the   roles   and  responsibilities  and  reporting  lines  of  key  individuals  within  MoHSW  P4P  structure  were  not  clearly  spelled  out  [KI  13].  The  head  of  the  still  existing  national  P4P  programme  remained  in  place  as  the  lead  on  CCHP  design  and  approval  –  in  which  P4P  was  one  component,  but  the  national  coordinator  did  not  play  a  role   in  the  Pilot;  the  MoHSW  seemed  to  be  saying  “we  do  not  want  her  to  be  the  one  to  oversee  this  pilot  and  maybe  it’s   important  that  she  doesn’t   do   this   anymore”,   noted   a   key   informant   [KI   13].   Further,   the   time   of   the   pilot’s  implementation   coincided  with   a   nationwide   doctors’   strike,   removal   of   the  minister   and  deputy  minister   for  health,  as  well  as   the  suspension  of   the  Permanent  Secretary  and  the  Chief  Medical  Officer.  Thus  the  pilot  was  “  ‘donor  driven’  without  ‘much  national  ownership’  and  largely  implemented  by  CHAI  at  a  time  when  the  decapitated  leadership  of  the  MoHSW  was  doing  little  active  decision  making”  [KI  13].    

The  PMORALG  should  have  been  the  key  persons  in  the  P4P  link  as  responsible  for  service  delivery.  Their  very  absence  and   limited   involvement   in  the  entire  P4P  decision  making  or  implementation  process,  was  a  key  gap  [KI  6,  21]:  “a  short  coming  for  the  P4P  but  also  for  the  basket  by  then”  [KI  21].  Inadequate  capacity  in  the  PMORALG  is  a  perennial  concern.  

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The   health   financing   technical   working   group,   ‘was   taking   more   of   an   active   role   in   the  evolution   of   P4P   to  whatever  was   going   to   come   out   after   the   pilot’,  noted   one  MoHSW  representative.   There   was   certainly   a   lot   of   learning   during   the   Pilot   implementation  process.  

Generally,   there   was   limited   collaboration   within   the   MoHSW   according   to   one  development  partner   representative  who  noted:   ‘there  were  a  number  of   small   kingdoms  within  the  ministry  and  they  were  used  to  dealing  with  their  own  donors  and  not  necessarily  collaborating   among   themselves…..seemed   a   bit   deliberate   from   some   of   them,   and   also  keeping  the  donors  apart  so  that  they  could  access  more  funds.’  This,  according  to  another  key  informant  [KI  13]  is  still  true  and  is  cross  cutting  across  all  programmes.  

In   January   2013,   the  MoHSW   coordinated   a   national   P4P   stakeholder  meeting   to   discuss  best  practice  P4P  models  within   the  Region,   as  well   as   lessons   learnt   from  P4P  pilot;   and  discuss  the  requirements  for  a  successful  rollout  (MoHSW  January  2013).    A  national  “time  limit”  taskforce45  was  put  in  place  to  “oversee  the  redesign  or  basically  this  transition  from  the   P4P   pilot   to   the   new   design   of   the   RBF   program”.   The   Task   Force   was   requested   to  prepare   a   P4P   review   and   options   paper   on   strategic   choices   for   sustainable   P4P   design  options  for  national  programme  linked  to  the  Health  Financing  Strategy.  Minutes  of  a  DPG-­‐Health  meeting  in  early  2013  notes  that  the  World  Bank  reiterated  the  need  for  the  creation  of  a  P4P  task  force  to  oversee  P4P  scale  up  plans  at  the  national  level.  With  the  addition  of  prospective   development   partner   donors,   the   Task   Force   was   intended   to   attract   health  basket  partners  to  support  the  scale  up  process,  and  make  sure  that  P4P  does  not  remain  viewed  as  a  stand  alone  bilateral  project,  but  as  a  system  strengthening  initiative.  

“…It  was  the  acting  Chief  Medical  Officer  or  the  Chief  Medical  Officer    ….  he  was  the  one  who  having  been  debriefed  about  P4P,  and  said  that  we  should  have  a  national  task  force.....it  was  hoped  that  P4P  wouldn’t  be  seen  as  a  kind  of  project  or  program  or  something  separate.    It’s  a  systems  strengthening  intervention  so  the  idea  was  to  have  a  wider  group  and  it  would  involve  more  partners  because  there  were  partners  who   were   potentially   interested,   partners   with   experience   and   who   weren’t  necessarily   interested   like   USAID,   you   had   the   Providing   for   Health   (P4H)   network  partners46   who   were   represented   because   they   were   supporting   health   financing  more   generally.   So   it   was   a   mix   of   DPs   and   technical   advisers   and   government  officials.’  MoHSW  representative.  

According  to  one  MoHSW  representative,  “after  the  pilot,  we  should  have  gone  to  the  roll  out   straight  away  and   that  didn’t  happen”,  mainly  because  of   “lack  of   funds.  No  one  was  ready  to  fund  for  the  whole  country.  Norway  was  funding  for  the  pilot  but  it  was  not  ready  to  fund  the  national  roll  out.’  The  Health  Basket  Funders  “were  not  ready  to  use  their  money  for  P4P”,  not  sure  why  but  perhaps  “they  were  not  satisfied  ….  .there  should  be  a  reason  but  the  reasons  usually  are  not  open”.  USAID,   for  example,  was   involved   in  the  redesigning  of  Pwani  P4P  pilot  (through  Broad  Branch  Associates).  Some  DPs  were  also  involved  in  the  P4P  advisory  committee  and  were  kept   informed  of   the  progress  of   implementation:   the  Pilot  Management  Team  “had  several  meetings  where  they  presented  and  they  (DPS)  were  very  

                                                                                                                         45  MOHSW  (Assistant  Director  Policy  and  Planning,  Manager  of  PWANI  p4P  Pilot,  Coordinator  of  District  Health  Services,  Policy  and  Planning  Advisor,  Health  Management  Information  System),    Prime  Ministers  Office,  Regional  and  Local  Government,    Providing  for  Health,  Health  Basket  Fund  partners,  Norway,  USAID,  World  Bank).  46  Including  GIZ,  KfW,  SDC,  USAID,  WB,  WHO  

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happy”,  but  “when  it  came  to  funding  there  was  this  gap.  They  were  not  ready.  …’,  noted  a  P4P  advisory  committee  member.  

Development  partners,  as  well  as  several  national  stakeholders  remained  concerned  about  how   the   initiative   will   be   sustained   in   the   long   run   –technically   and   financially   (IHI   June  2013)(see  Tables  9,  10,  11).  

The   Pwani   pilot   was   supposed   to   be   implemented   for   two   years   from   Jan,   2011   to   Dec,  2012,  but   the  Pilot  Management  Team     “managed   to  use   the   funds  up   to  3  years   [to  end  2013]  because  the  facilities  were  not  able  to  earn  all  the  money  which  was  allocated  for  P4P  for   those   two  years..”   [KI  1].  Norwegian   funding   for   the  P4P  pilot  ended   in  Dec  2013  and  their  support  to  CHAI  in  June  2014.  The  MoHSW  is  now  overseeing  the  Pilot  with  financial  support  from  the  World  Bank  who  had  agreed  with  Norway  to  continue  financing  P4P  Pwani  till  the  Region  is  integrated  into  national  RBF  roll  out  (and  using  Norwegian  funds  channeled  to  the  World  Bank  group).  Funds  were  expected  to  flow  through  the  Ministry  of  Finance  and  Economic   Affairs   (though   eventually   this   did   not   happen)   calling   for   a   new   agreement  between  the  Government  of  Tanzania  and  the  World  Bank  which  was  still  being  finalised  in  March  2015  and  two  sets  of  payments  had  been  delayed.  The  Ministry  of  Health  and  Social  Welfare  has  prepared  a  revised  P4P  design  document  and  operational  manual  to  guide  the  transition   period,  where   some  of   the   structures   and   processes   for   implementing   the   P4P  scheme   have   changed   (MoHSW   March   2015).   Thus   health   workers   and   their   facilities  continue  to  receive  bonus  payments,  though  there  is  no  recent  information  on  how  many  of  these   facilities   are   continuing   to   implement   the   P4P   scheme.   Available   evidence   from   a  monitoring  visit  by  IHI  researchers  in  February  2015  to  Kisarawe  and  Mkuranga  districts  of  Pwani  suggest  a  scaled  down  data  verification.    

   

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Table  9.  Influence  and  position  of  key  actors  during  Phase  IV  of  the  RBF  policy  formulation  process  –  2010-­‐2013,  Pwani  P4P  Pilot  and  Early  Roll  Out  Plans  

 

Table  10.  Phase  IV  –  Facilitators  and  Barriers47  

Facilitators   Barriers  Key  Actors   Key  Actors  • GoT  agrees  to  a  Pilot.  • Government  requests  CHAI  for  their  

support  in  the  management  and  implementation  of  P4P  Pilot;  and  IHI  to  undertake  the  evaluation  of  the  Pilot.  

• Support  from  Norway,  Norad,  RNE,  CHAI,  IHI/LSHTM/CMI  and  USAID  (through  Broad  Branch  Associates).  

• MoHSW  had  authority  on  deciding  on  the  payment  model.  

 

• Pwani  Pilot  operated  externally  (CHAI)  with  minimum  involvement  of  MoHSW  (outside  of  those  directly  involved  in  the  PMT)  

• MoHSW  limited  authority  on  use  of  funds  for  implementations  process  i.e.  Norway  controlled  and  channelled  management  and  operation  funds  through  CHAI  as  the  key  signatory.  

• Assigned  national  P4P  coordinator,  without  a  resource  portfolio  (and  

                                                                                                                         47  Table  7  provides  additional  facilitators  and  barriers  based  on  impact  evaluation  findings    

  SUPPORTIVE   NOT  MOBILISED  /  NEUTRAL  

OPPOSED  

LEVEL  OF  INFLUENCE  

H   M   L     L   M   H  

High   GON/Norad/RNE  –Tz  

GoT  

 

    World  Bank?  

     

Medium   USAID/BBA,  CHAI       Health  Basket  Fund  (Irish  Aid,    DANIDA,  Swiss  Devpmt.  Corp.  

       

Low   NHIF,  WAJIBIKA,  Cordaid,  IHI/LSHTM  

Pwani  health  providers  &  Pwani  district  and  regional  managers  

MoSHW  (P4P-­‐  Coord.),  HF-­‐TWG,  HMIS,  Policy  &  Planning)  

Providing  for  Health  

  P4P  ADVISORY  COMM.  MEMBERS  (some)  

Community  

MoHSW  (Some)  

Researchers  (Some)  

Civil  Society  (Some)  

PMO-­‐RALG*  

MoHSW  (some)  

Researchers  (some)  

   

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  consequently  with  limited  decision  making  powers  on  implementation  process)  

• Tension  among  the  key  actors  in  the  P4P  structure  within  MoHSW  (RCH  unit,  National  P4P  programme  and  P4P  pilot)    

•  Limited  involvement  of  PMO-­‐RALG  in  P4P  pilot  as  well  as  in  the  Basket  

• Limited  involvement  of  some  of  the  key  local  government  authority  decision  making  bodies  in  the  implementation  process  –  district  executive  director,  council  health  service  board,  health  facility  governing  committees  (in  the  beginning)  

Context   Context  • Pilot  as  a  bilateral  project  (Norway-­‐

Tanzania)  framed  to  inform  national  programme  

• Norway  has  control  over  use  of  P4P  funds  • CHAI  good  working  relationship  with  the  

Government  and  with  Norway      

• Time  bound:  under  tremendous  pressure  to  implement  in  a  short  period  of  time  –  a  learning  by  doing  approach  

• Donor  dependent  with  limited  national  ownership    

• Little  direct  financial  support  from  GoT  to  MoHSW;  Norwegian  support  for  management  and  operation  (i.e.  implementation  process)  of  P4P  pilot  channelled  through  CHAI  

• Tension  within  the  MOHSW  P4P  structure  (internal  politics)  with  consequences  for  lack  of  clarity  in  reporting  lines  

• Doctors’  Strike  resulting  in  removal  of  Minister  and  Deputy  Minister,  and  Suspension  of  Permanent  Secretary  and  Chief  Medical  Officer  

• Weak  capacity  of  PMO-­‐RALG;  MoHSW  in  centre  of  P4P  and  the  Basket,  with  implications  for  resource  management,  availability  and  service  delivery  at  local  government  level,  which  is  the  responsibility  of  PMO-­‐RALG  

• Delayed  and  varying  involvement  of  Health  Facility  Governing  Committees  

• A  constrained  health  system  with  several  systemic  issues  &  limited  time  and  funds  to  address  these  constraints  

• Inadequate  financial  support  for  supervision  and  verification  processes  

• The  Norwegians  could  not  inject  more  funds  towards  system  strengthening  (i.e.  facility  incentives)  as  they  were  already  funding  the  basket  which  aims  to  do  the  same  thing.    

• Limited  financial  support  /  appetite  for  a  national  roll  out  among  development  partners  (mainly  due  to  concerns  

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regarding  capacity  of  the  system  and  inadequate  P4P  evidence)  

• Concerns  regarding  sustaining  and  scaling  up  the  initiative  -­‐  financially,  technically  and  managerially  

Content   Content  • Addressed  some  of  the  weaknesses  of  the  

first  national  design,  but  with  a  focus  on  maternal  newborn  health  

• Timely  monthly  reporting  of  data  by  the  facilities  over  time  

• Improved  working  relationships  between  health  workers  and  their  managers  over  time  

• Substantial  amount  of  data  error  was  reportedly  being  captured  by  the  District  Health  Information  System  

• P4P  beginning  to  be  viewed  as  a  system  strengthening  initiative    

• Institutional  setup  –  no  separation  of  functions    

• Frequent  changes  to  key  design  features  over  time  (as  it  adapted  to  emerging  constraints  and  challenges),  resulting  in  confusion  at  council  and  facility  level  

• Weak  and  ineffective  communication  of  information  between  various  levels  of  the  system  

• Payment  model  -­‐  split  between  health  workers  within  the  facility  (RCH  vs.  non-­‐RCH)  with  potential  negative  consequences  for  team  work;  limited  proportion  of  facility  improvement  funds  to  address  systemic  constraints,  compared  to  motivation  payments  for  health  workers  

• Concerns  regarding  quality  of  monthly  data  reported  by  facilities  

• Implementation  process  required  massive  support  (technically,  operationally  and  financially)  

• Health  Facility  Governing  Committees  not  part  of  the  P4P  process  to  begin  with;  subsequently  incorporated.  

Processes   Processes  • Structures  set  up  to  support  the  

implementation  of  the  Pilot  –  advisory  and  steering  committees.  

• P4P  national  task  force  (broad  based)  established  to  oversee  scale  up  plans–beginnings  of  an  inclusive  process  with  some  consensus  amongst  basket  fund  partners  

• Regular  PMT  meetings  and  field  visits;  joint  HMIS  trainings.    

• P4P/HMIS  training  sessions  for  some  health  workers  and  their  managers  facilitating  a  good  understanding  of  the  Scheme  

• Use  of  score  cards  to  promote  transparency  in  payments  at  facility  level  

 

• Delays  in  signing  P4P  pilot  implementation  contract    

• Advisory  and  Steering  committees  met  irregularly  and  were  ineffective.  

• Time  consuming  and  costly  verification  process  

• Absence  of  ongoing  facility-­‐based  P4P/HMIS  trainings  addressing  emerging  needs  

• Facility  supervision  increasingly  focused  on  P4P  activities  and  on  verification  processes,  rather  than  on  content  of  quality  of  care  

• Score  cards  not  updated  to  reflect  changing  human  resource  composition  at  facility  level  

       

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b. Evaluation  of  the  P4P  Pilot  

The  Norwegian  Embassy  commissioned  IHI  to  undertake  an  independent  evaluation  of  P4P  Pilot   (Aug  2011-­‐May  2013,  22  months);   subsequently  extended   to  a  29  month  evaluation  (Aug  2011-­‐Dec  2013)   (Borghi  et  al  2013).  An   impact  evaluation  assessed   the  effect  of   the  P4P   initiative   on   the   quality   and   coverage   of   targeted  maternal   and   newborn   healthcare  services   and   selected   nontargeted   services   at   facilities.   A   process   evaluation   examined  whether   the   P4P   programme  was   implemented   as   planned,   stakeholder   response   to   the  programme   and   its   acceptability   and   potential   unintended   consequences;   and  implementation   bottlenecks   and   facilitating   factors.   The   economic   evaluation  was   carried  out   from  a   societal   perspective   and  aimed   to   ascertain  whether  P4P   represents   value   for  money;   it   examined   the   effect   of   the   P4P   programme   on   quality,   coverage,   and   cost   of  targeted  maternal  and  newborn  healthcare  services  and  selected  non-­‐targeted  services  at  facilities  in  Tanzania.  A  consortium  of  researchers  from  IHI,  LSHTM  (UK)  and  CMI  (Norway)  carried  out  the  evaluation.  It  aimed  to  contribute  robust  evidence  on  the  impact  and  cost-­‐effectiveness  of  P4P  in  a  low  income  setting,  as  well  as  generate  a  better  understanding  of  the  feasibility  of  integrating  complex  intervention  packages  like  P4P  within  health  systems  in  resource  poor  settings.    

The   evaluation   findings   were   disseminated   in   December   201348.   Overall,   impact   results  were   mixed   and   inconclusive.   There   was   an   improved   coverage   of   some   incentivized  services   (for   malaria   and   deliveries);   and   improvements   in   some   aspects   of   the   work  environment   that   are   valued   by   health   workers.   However,   there   was   no   effect   on   most  aspects  of  quality.  But  then  one  could  hardly  expect  any  substantially  bigger  effects  of  P4P  in  the  13  month  period  that  the  impact  evaluation  lasted  than  what  was  observed.  Beyond  that,  there  were  a  number  of  positive  experiences,  along  with  a  number  of  challenges.  The  process  promoted  team  spirit  amongst  RCH  workers,  stimulated  innovation  at  facility  level  to   address   systemic   constraints   and   resulted   in   timely  monthly   reporting   of   facility   level  routine  data.  There  were   concerns   for  potential  displacement  of  non-­‐targeted   (non-­‐MCH)  services  (especially  in  dispensaries);  for  divisiveness  in  larger  facilities  due  to  unequal  bonus  payments  (RCH  vs.  non-­‐RCH  staff),  &  smaller  facilities  (clinical  vs.  non-­‐clinical);  as  well  as  for  potential  equity  issues  between  facilities.  Notwithstanding  the  number  of  limitations  to  the  costing  study,  the  findings  provide  useful  insights  on  how  best  to  sustain  a  national  scale  up.  In   2012  US   dollars,   the   financial   cost   of   the   P4P   performance   pilot  was   $1.2  million;   the  economic  cost  was  $2.3  million;  and  the  incremental  cost  per  additional  facility-­‐based  birth  ranged   from   $540   to   $907   in   the   pilot   and   from   $94   to   $261   for   a   national   program.  Managing  the  P4P  program  was  the  most  costly  component  of  ongoing  implementation  and  exceeded  the  costs  of  financial  incentives  by  between  1.7  times  (in  financial  costs)  and  1.9  times   (in   economic   costs).   Performance   data   reporting   and   verification   costs   were  substantial,  ranging  from  36%  to  50%  of  the  economic  costs.  The  research  team  concluded  that   in  a   low-­‐income  setting,   the   costs  of  managing  a  pay-­‐for-­‐performance  program,   “are  substantial   and   greatly   exceed   the   costs   of   incentive   payments   themselves”;   P4P  programmes   “may  become  more   cost-­‐effective  when   integrated   into   routine   systems  over  time”   (Borghi   et   al   2015).   Table   11   provides   a   summary   of   evaluation   findings   and  implementation  challenges).    

                                                                                                                         48  See  www.ihi.or.tz  for  presentations  

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In  a  keynote  speech  made  during  the  dissemination  of  the   impact  evaluation  findings,  the  Guest  of  Honor  Dr.  Mwinyi,  (Minister  of  Health,  MoHSW)  remarked  that  RBF  is  not  a  stand-­‐alone  intervention,  but  should  be  viewed  within  broader  health  system  reforms.    

There   are   two  major   limitations   to   the   evaluation.   The   timing   of   the   baseline   evaluation,  which   took  place  during   the   course  of   the   first  payment   cycle  but  before  payments  were  made   in   most   cases;   the   risk   is   that   baseline   data   will   already   be   affected   by   the  intervention,  minimising   the   overall   observed   P4P   effect.   A   further   limitation   is   the   short  time  frame  for  the  impact  evaluation  that  evaluates  effects  over  a  one  year  period;  and  it  is  very  possible  that  the  over  time  the  effects  could  have  been  greater  or  lesser  or  the  same  (Borghi  et  al  2013).  

More   recent   findings   on   the   long   term   effects   in   Pwani   following   an   end   line   evaluation  after   36   months   of   Pilot   implementation,   suggest   that   the   effects   on   targeted   services  reduced  over  time  (the  effect  on  deliveries  halved,  and  no  effect  on  IPT  (malaria)  any  more);  and   the   earlier   negative   effects   on   non-­‐targeted   services   at   dispensary   level   disappeared  over  time.    (Borghi  et  al,  July  2015).  However,  provider  kindness,  payment  for  delivery  and  availability   of   drugs   sustained   over   time.   These   findings   need   to   be   viewed   within   the  context  of  a  delay   in   securing  an  agreement   for  World  Bank   take  over  of   scheme   funding  resulting   in   considerable  delays   in  bonus  payments;   less   intense   technical  and  managerial  support  (with  withdrawal  of  CHAI  support);  and  a  scaled  down  verification  system  with  no  feedback  sessions   in  the  past  twelve  months.  Perceptions  and  acceptability  of  the  scheme  remains   high   –   thus   as   noted   by   Borghi   et   al   (July   2015),   while   the   incentive   effect  maintained,  the  resource  effect  disappeared.  

The   Pwani   evaluation   according   to   one   key   informant   (KI   13),   “masked   a   lot   of   the   best  effects  of  the  program”.  As  noted  earlier,  the  Pilot  was  designed  in  a  rush  because  the  funds  were  time  bound,  and  implemented  under  pressure.  Pwani  did  not  have  a  monthly  routine  quality   check   system   in   place.   The   Pilot   had   to   financially   and   technically   support   the  creation   and   implementation   of   one,   and   then   of   the   District   Health   Information   System  [DHIS]  system  on  top  of  it.  Even  though  the  roll  out  of  the  DHIS  which  was  also  a  Norwegian  supported  initiative,  was  done  in  a  very  haphazard  way,  it  got  “much  higher  compliance  and  much  more   reporting   rates”  because  health  workers  and   their  managers  were  well  aware  that  without  the  monthly  routine  reporting  there  was  no  chance  of  performance  payments.  Given   existing   human   resource   resources   constraints,   errors   in   routine   data   entry   at   the  facility   level   were   inevitable.   More   important,   each   round   of   verification   revealed   that  perhaps  not  all  but  still  “a  substantial  amount  of  [routine  facility  level]  data  reporting  error  can  be  captured  by  the  system,”  [KI  13].    

   

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Table  11.  P4P  pilot  evaluation  -­‐  summary  findings  Achievements  (over  time  and  in  the  short-­‐term)  Bonus  Payments  • Almost  all  government  facilities  have  bank  accounts    • ‘Performing’  facilities  benefited  from  additional  resources  • Health  workers  empowered  –  have  control  over  money  and  use  of  facility  funds  to  meet  

immediate  need  • Increased  transparency  at  facility  level  regarding  bonus  funds  through  score  cards  • Targets  felt  to  be  achievable  at  upper  levels  • Bonus  payments  felt  to  be  adequate  at  lower  levels    • Promoted  team  spirit  at  primary  facilities  (among  RCH  workers)  • Stimulated  innovation  to  meet  targets  (at  facility  and  district  level)  Performance  verification  • Troubleshooting  and  resolving  implementation  issues  in  health  management  information  system  

(HMIS)    • Improved  timeliness  of  reporting  • Greater  appreciation  of  value  of  HMIS  data  • Strengthened  relations  between  health  workers  and  their  managers  –  more  frequent  ‘contacts’  Impact  • Potential  for  improved  content  of  care  when  directly  incentivized  • Improved  coverage  of  some  incentivized  services  (for  malaria  and  deliveries)  • Improved  some  aspects  of  the  work  environment  that  are  valued  by  health  workers  Constraints    Design  • Performance  targets  based  on  out  dated  population  data  • Performance  indicators  and  set  targets  were  system  based  and  demand  and  supply  side  factors  

affected  ability  to  meet  targets  (especially  for  smaller  facilities)  • Financial  architecture  of  faith  based  systems  did  not  allow  for  facility  bank  accounts  • Assumed  integration  of  verification  into  existing  routine  supportive  supervision  visits  –  

inadequately  resourced  (implications  for  data  quality)  • Absence  of  clear  criteria  for  bonus  payment  at  council  level  • Scorecards  not  updated  to  reflect  changes  in  facility  staffing  • Difficulties  in  managing  and  sustaining  bank  accounts,  especially  smaller  facilities  (cost  

implications)  • Cost  of  current  management  (and  administrative)  structures  (largely  exceed  payouts)  • Time  (and  cost)  implications  of  data  gathering  and  verification  -­‐Substantial  cost  burden  on  the  

health  system  largely  borne  at  district  level  and  below  Implementation  • National  structures  set  up  to  support  pilot  implementation  -­‐  steering  committee,  advisory  board  –  

not  very  effective  • Not  all  facility  staff  oriented  to  P4P  and  new  HMIS  system  –  short  training  periods,  absence  of  

refresher  trainings  • Inadequate  and  delayed  disbursement  of  funds  at  all  levels  of  the  system  • Inadequate  communication  about  design  and  indicator  changes  over  time,  and  confusion  around  

qualifying  criteria  for  P4P  facilities  • Weak  mechanisms  to  ensure  accountability  in  appropriate  use  of  facility  funds  –  limited  ability  of  

health  facility  governing  committees  to  monitor  use  of  facility  level  funds  and  at  council  level  • Concerns  regarding  quality  of  performance  data,  weak  internal  verification  and  costly  external  

verification  process;  timely  completion  of  HMIS  registers  and  tally  sheets  an  added  burden  to  staff  constrained  facilities  

• Absence  of  supportive  supervision  visits  (with  a  focus  on  P4P  activities  and  verification)  

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• Delays  in  cycle  payments  (time  consuming  verification  and  certification  process)  • Requires  decentralised  financial  management  system  and  system  of  accountability  for  fund  

management  and  use  • Required  considerable  financial,  technical  and  operational  support  Impact  Impact  • No  effect  on  most  aspects  of  quality    Potential  Risks  Design  • Potential  for  divisiveness  in  larger  facilities  due  to  unequal  bonus  payments  (RCH  vs.  non-­‐RCH  

staff),  &  smaller  facilities  (clinical  vs.  non-­‐clinical)  • Potential  displacement  of  non-­‐targeted  (non-­‐MCH)  services  (especially  in  dispensaries)  • Potential  equity  issues  (with  some  facilities  in  better  concerns)  Implementation  • Sustaining  high  scale  up  costs  –  potential  sources  for  national  roll  out  not  identified  Impact  • Potential  effect  on  waiting  time  of  targeted  services  Implications  for  the  design  (for  the  scale  up)  Indicators  • Revisit  choice  of  performance  indicators  (quantity  vs.  quality  of  care,  beyond  MNCH  services)  Targets  • Lower  coverage  targets  (more  scope  to  improve),  but  more  pro-­‐poor  effects  when  coverage  is  high  • Ensure  targets  are  context  specific,  achievable  and  within  health  worker  control  • Incentivise  improvements  in  clinical  quality  of  care  to  ensure  improvements  in  health  outcomes  Bonus  system  • Consider  introducing  variations  in  bonus  levels  by  level  of  care  and  facility  ownership  type  • Consider  including  all  health  workers  (not  just  RCH)  towards  a  system  wide  impact  • Examination  of  the  balance  between  health  workers  versus  facility  level  bonuses  • Bonus  payments  may  need  to  be  increased  over  time  to  sustain  effects  (implications  for  

sustainability?)  Non  financial  incentives  • Provide  additional  basic  resources/health  system  strengthening  to  increase  health  worker  

opportunity  to  perform  • Adequately  financing  of  supportive  supervision  • Build  performance  appraisal  system  and  opportunities  for  promotion.      Management  • Address  financial  architecture  of  faith  based  facilities  • Need  for  essential  governance  &  oversight  structures  at  all  levels  • Test  more  efficient  fund  holder  arrangements  • Revisit  payment  mechanisms  (especially  to  smaller  facilities)  • Effective  communication  strategies    Data  gathering  • P4P  HMIS  trainings  -­‐  Ongoing,  periodic,  hands-­‐on,  financially  feasible,  adapted  to  context  • Rolling  out  of  the  new  HMIS  a  prerequisite  • Cost  implications  Verification  • Test  alternative  and  more  efficient  verification  and  certification  processes  • Strengthen  community  monitoring  systems  –  monitor  patient  experience,  community  felt  needs.    

Source:  www.ihi.or.tz;  Borghi,  et  al  2013,  2015;  IHI  June  2012,  Dec  2012,  June  2013;  Olafsdottir  et  al  2014    

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3.2.5 Phase  V:  Transitioning  from  pay  for  performance  to  results  based  financing,  mid-­‐June  –  December  2013    

With   ongoing   discussions   and   emerging   plans   for   a   national   scale   up,  Norway   decided   to  engage   more   with   the   World   Bank   and   solicit   their   support   as   they   did   not   have   the  required  capacity.  Also,  Norway  was  once  again  planning  to  move  out  of  Tanzania’s  health  sector.  Norway  approached  the  World  Bank  to  “explore  potentials  for  including  Tanzania  in  the  World  Bank  managed  Health  Results  Innovation  Trust  Fund  (HRITF),  and  also  facilitated  discussions  with  GAVI  and  the  Global  Fund  to  co-­‐fund,  i.e.  ‘procure’  selected  RBF  indicator”  [KI  19].    

The  HRITF  that  is  located  in  the  World  Bank  was  established  by  Norway  in  2007  focusing  on  MDG  4  &  5,   improve  health  results  through  health  systems  strengthening  and  explore  the  value  of  RBF   as   a   tool.   The  HRITF  was   co-­‐funded  by  Norway  and   the  UK.   The  majority  of  Norwegian  RBF  funding  under  the  health  initiative  has  been  channeled  through  the  HRITF,  and  Gavi,  the  Vaccine  Alliance  (Olsen  2009).  Norway  has  committed  Norwegian  Kroners  2.1  billion  to  the  fund’s  activities  during  the  period  2007–2022  (Lindqvist  &  Bastoe  2015).   It   is  through  HRITF  that  the  World  Bank  became  very  active  in  the  RBF  global  landscape  –  they  had  the  geographical  presence  and  the  technical  capacity  and  now  the  financing  to  do  so.  And  now  nationally  (in  Tanzania).  A  very  smart  and  strategic  move  by  Norway,  commented  one  key  informant  [KI  21].  

By  June  2013,  the  Norwegian  Embassy   in  Dar  es  Salaam  had  already  entered  into  national  scale  up  discussions  with  the  WB:  taking  into  consideration  lessons  learned  from  the  Pwani  pilot  and  “whatever  modifications  we  needed  to  make  to  the  pilot  to  make   it  scalable”  [KI  16].  The  “USAID,  World  Bank  and  Norway  formed  the  first  team  to  start  looking  at  options  [the   Health   Financing   Strategy   options   paper49]   and   they   [USAID]   hired   an   international  consultant   [Broad   Branch   Associates]”;   DANIDA   had   been   funding   an   RBF   initiative   in  Zanzibar   for   some  time  and  “was  also   interested…to  be  part  of   the  discussions”   and   learn  from  the  process  [KI  16].  

The  World  Bank  forged  ahead  without  waiting  for  the  P4P  impact  evaluations  results  which  were  released  in  December  2013,  “because  the  Bank  wanted  to  move  really  fast”  on  the  RBF  agenda  [KI  18];  or  else  it  would  be  “  too  late  to  have  Tanzania  included  as  a  part  of  HRITF,  mainly   as   other   countries   were   on   the   wait   list”   [KI   19].   With   support   from   Norad   and  USAID,   the   Bank   in   mid-­‐2013   commissioned   a   team   of   consultants50   to   undertake   a  ‘multistakeholder’  national  RBF  assessment  in  Tanzania.  The  assessment  was  part  of  a  series  of   papers   informing   the   Health   Financing   Strategy   –  with   RBF/   P4P   at   that   time   seen   by  partners  and  the  health  financing  technical  working  group  as  part  of  health  financing  more  generally.  The  idea  was  to  review  all  existing  RBF  schemes  in  the  country,  including  the  P4P  pilot,  and  elsewhere  (Rwanda,  Argentina),  and  develop  a  comprehensive  programme  model  which  the  World  Bank  would  be  able  to  support  later  on  using  Trust  Funds.    

“There  was  an  assessment  carried  out  by  the  World  Bank...we  went  even  beyond  the  Pwani   pilot   to  Mvomero,   Iringa,   Rungwe   and  we   interviewed   stakeholders   [health  care  providers,  managers].  They  suggested   improvements   to   increase   incentives,   to  increase  service  delivery  beyond  maternal  &  child  health….  there  was  a  lot  of  advice  

                                                                                                                         49  For  an  assessment  of  the  Health  Financing  Strategy  50    Included  representatives  from  DANIDA,  BroadBanch  consultant  and  MoHSW  (present  RBF  coordinator).  

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that  was  collected  from  that  assessment,”    (MoHSW  representative).  

The  assessment  resulted  in  recommendations  for  a  national  scheme,  noted  the  World  Bank  representative   and   further   confirmed  by   the  MoHSW.  According   to   one   key   informant,   it  was  a  “weak”  assessment,  [KI  17].  

Around  the  same  time,  on  June  21st  2013,  Cordaid,  the  Christian  Social  Services  Commission  (CCSC)  and  the  Kilimanjaro  Christian  Medical  Centre  (KCMC)  organized  a  national  PBF  forum  in  Bagamoyo.  It  was  well  attended  by  development  partners,  government  institutions,  and  civil  society  representatives  from  other  international  and  national  organisations.  The  Forum  went   on   to   recommend   the   adoption   of   RBF   as   the   health   financing   model   to   improve  quality  of  care   in  Tanzania,  but  also  reiterated  that   its  successful   implementation  requires  political   support,   strong   independent   verification   system   and   conducive   policies   to   back  PBF.51  CORDAID  also  organized  RBF  study  tours  for  Tanzanian  officials,  and  an  international  PBF  Conference   in  Dar   es   Salaam   that   sensitized   some  high   level   government   officials   on  PBF  benchmarking.    

In   November   2013,   the   MoHSW   coordinated   a   four   day   P4P-­‐RBF   workshop/training   in  Bagamoyo  to  garner   ideas   for   the  redesign,  and  to  expand  the  pool  of  MoHSW  and  other  Government   officials   who   understood   what   P4P/RBF   was,   given   that   it   was   intended   to  scale   up,   and   that   the   implications   go   beyond   financing   through   to   service   delivery   (see  Table   12).   The  meeting  was   co-­‐facilitated   by   an   independent   and   experienced   facilitator,  and   attended   by   a   broad   range   of   stakeholders,   including   from   various   government  ministries,   health   development   partner’s   as   well   as   from   other   countries   with   RBF/P4P  initiatives,  such  as  Argentina,  Zambia  and  Rwanda    [KIs  2,  3,  10,  17].  On  the  last  day  of  the  workshop,   IHI  was   invited   to   share   preliminary   impact   evaluation   findings,   as  well   as   the  several  design  and   implementation  challenges  and  emerging  concerns  with   respect   to   the  planned  roll  out.    

“The  World  Bank  came  in  and  said  they  were  going  to  take  care  of  funding  but  with  modifications  …from  2014,  and  the  modifications  carried  out  resulted  into  renaming  of  the  P4P  to  results-­‐based  financing  (RBF),”  [MoHSW  representative].  

The  Bagamoyo  workshop  transitioned  from  “training,  to  pre-­‐planning  to  awareness  creation  of  a  potential  roll  out  or  at  least  levelling  the  ground  for  the  stakeholders  whether  to  roll  out  Pwani,   or   whether   to   develop   a   new   concept….   it   was   a   shift   from   that   singular   project  [Pwani   P4P]  which  was   thought   to   have   some   valuable   experiences   but   having  also   some  short   comings   and   it   was   recognized   that   a   fully-­‐fledged   RBF   system   would   have   to   be  expanded  somehow  and  detailed,  designed  in  detail.”  [KI  10].    

There  remained  some  “reluctance”  amongst  “some  of  the  basket  partners”;  “they  wanted  to  see   results   first   before   committing   themselves”,   [KI   18].   The   concerns   of   basket   partners,  according  to  one  key  informant  [KI  9]  were  several,  including  those  related  to  harmonisation  with  health  system  strengthening  priorities;   integration  with  CCHP  planning  and  budgeting  which  the  health  basket  fund  partners  had  long  endeavoured  to  support;  and  concerns  over  equity,  over  a  design  originally  focused  primarily  on  outputs  and  not  on  quality  and  about  skewing  health  workers’  expectations  without  a  thorough  understanding  of  health  workers’  motivations,  etc.  

                                                                                                                         51  http://pbf-­‐rungwe.blogspot.com/  

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A   national   broad-­‐based   RBF   task   force52   for   the   roll   out   was   put   in   place   under   the  leadership  of  the  Assistant  Director  of  Policy  and  Planning,  MoHSW.    The  MoHSW  and  the  World   Bank   wanted   to   ‘make   sure   that   all   the   other   partners   who   may   or   may   not   be  interested’  are  part  of  the  process  at  this  early  stage.  They  wanted  to  generate  ‘a  lot  more  buy  in  across  the  board’,  make  sure  that  it  is  not  viewed  as  ‘a  donor  driven  process’  but    ‘a  government  process  which  the  Bank  can  simply  support….this  was  very  crucial;  people  at  the  government  should  know  what  the  scheme  is,  if  they  don’t  know  you  can’t  run  it  in  the  long  run.’  (KI  18).  And  Providing  for  Health  partners  in  general  wanted  to  make  sure  that  RBF  is  not   designed   in   isolation   but   as   part   of   the   Health   Financing   Strategy   development  unfolding  at  the  same  time.  

a. Scale  up  process:  evidence  informed?  

Stakeholder   opinions   are   mixed   as   to   whether   Pwani   evaluations   informed   the   national  design  and  scaling  up  decisions.  

A   couple   of   interviewed   stakeholders   were   strongly   of   the   opinion   that   the   evaluation  findings  were  unequivocal  and  did  not  support  a  scale  up  process  (KIs  6,  7).  And  the  change  in  terminology   from  P4P  to  RBF  represents  a  political   rebranding  more  than  a  substantive  theoretical  difference  in  approach,  to  attract  more  resources  and  different  implementation  arrangements  (KIs  7,  13).  

The   general   feeling   is   that   Pwani   evaluation   results   were   cherry-­‐picked   and   used   as  arguments  for  scaling  up  RBF  where  they  were  supportive,  and  dismissed  as  based  on  too  short  a  timeframe  when  not  supportive  (KIs  2,5,10,  14,  17).  As  noted  by  one  key  informant  (KI14),  despite  the  short  evaluation  time  frame  of  a  year,  findings  suggested  “some  clearly  positive   impacts   and   there   were   impact   scenarios   where   the   government   wants   to   see  impact”,   such   as   in   relation   to   financial   protection   for   delivery   care   and   the   rate   of  institutional  deliveries.    

On  the  pattern  of  the  scale  up,  several  concerns  were  raised  during  the  Pwani  Pilot  that  it  was  being  implemented  in  an  overall,  better  resourced  and  better  supported  region  and  it  would  be  good  to  pilot  test  and  get  an  impact  in  a  more  underserved  remote  region.  Hence  an   explicit   decision   was  made   “to   try   and   channel  more   resources   to   an   area   which   has  typically  been  under  resourced  and  under  supported  …  to  test  whether  you  can  achieve  those  [positive]  results  somewhere  that  has  a  very  different  context  and  a  different  health  systems  environment,   [KI  10].    Shinyanga  was  selected  “after   looking  based  on  the  midterm  review  looking  at  poverty   level,  weakness  of   system  and  other   indicators  especially  maternal  and  newborn   and   the   rest,”   [KI   5].   Another   central   concern   was   to   do   with   the   verification  system:   “how   can   the   structures   that   were   designed   for   the   Pwani   pilot   be   scaled   up  nationally,  because  you  cannot  have  a  verification  committee  at  a  national   level  reviewing  the  data  for  all  regions….  so  we  need  to  look  at  a  more  decentralized  way  of  assessment”  [KI  5].    

On   the   whole,   as   noted   by   another   key   informant   (KI   19),   “there   is   an   absolute   lack   of  evidence  on  how  to  do  this  and  on  what  context  it  can  really  be  a  good  strategy”;  while  the  experience  of  Rwanda  and  Burundi  is  quite  promising,  “the  models  are  quite  different”.  Also,                                                                                                                            52   The   Task   Force   comprised   of   development   partners   from   World   Bank,   United   States   Agencies   for   International  Development  (USAID),  GIZ,  DFID,  SDC,  P4H,  Norad  as  well  as  MoHSW  and  PMORALG  officers.  .      

 

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there  are  many  dimensions  to  scaling  up:  “scaling  up  in  number  of  areas,  and  scaling  up  in  terms  of  making  it  more  comprehensive  and  streamlining  of  financial  mechanisms.  And  so  “  If  we  are   talking  about  more  districts…doing  exactly   the   same   thing  as   in  Pwani,  with   the  exact  same  type  of  support  then  I  think  that  evidence  is  strong  enough  to  say  that  this  is  not  that  risky.  Whether  it’s  the  best  thing  that  is  a  different  issue.    But  when  it  comes  to  making  it  the  financing  mechanism  country  wide  in  a  large  country  like  Tanzania,  with  very  different  regions  and  so  on,  that  is  a  different  issue  and  I  think  the  evidence  is  very  weak.”  

In   the   main,   scaling   up   decisions   were   political,   yet   evidence   informed.   The   Pwani  evaluation   served   its   purpose   and   “helped   to   inform   the   decision   that   it   was   worth  persevering”.  Basically  the  attitude  was  that  the  scale  up  would  not  be  the  replication  of  the  Pwani  work;  but  lessons  learned  from  Pwani  will  inform  the  redesigning  of  it.  Lessons  from  many   other   countries   have   also   been   taken   on   board,   including   via   consultants   from  Argentina,   Kenya,   Rwanda   and   Turkey.   For   example   the   decision   to   undertake   facility  assessments   to   ensure   facilities   can   provide   quality   care,   prior   to   implementing   RBF  was  based  on  Zambia’s  experience,  noted  the  RBF  coordinator.  Overall,    “it   is  a  combination  of  growing  evidence  and  individual  influence  …you  know  there  are  multiple  factors  that  are  not  all   aligned   in   one   direction”,   according   to   a   key   informant   [KI   14].   Time   will   tell   if   the  planned  approach  is  the  best  way  forward  for  Tanzania.  

   

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Table  12.  Phase  V    –  Facilitators  and  Barriers  

Facilitators   Barriers  Key  Players   Key  Players  • Norway  and  the  World  Bank  come  to  an  

agreement  on  the  way  forward  on  Tanzania’s  national  P4P/RBF  programme  

• World  Bank  emerges  as  a  key  player  globally  and  nationally  (with  technical  capacity  and  using  Trust  Funds  channelled  through  the  Bank)  

• Growing  commitment  and  support  from  GoT,  MoHSW  and  other  line  ministries  

• Health  basket  partners  concerns  prevails,  many  linked  to  harmonisation  of  RBF  approach  with  health  system  strengthening  initiatives  

Context   Context  • RBF  beginning  to  be  viewed  as  part  of  broader  

health  financing  and  systems  reforms  • MoHSW  coordinated  national  RBF  forum,  financed  

by  the  World  Bank  and  co-­‐facilitated  by  an  independent  consultant,  pulling  together  a  cross  section  of  stakeholders  to  garner  ideas  towards  the  redesign  of  the  P4P  towards  a  more  feasible/suitable  model  for  Tanzania  –  awareness  creation  and  conceptual  shift  from  project  based  P4P  to  national  RBF  system,  aiming  for  a  broader  buy  in  among  national  stakeholders  and  health  development  partners.  

• World  Bank  moving  forwards  on  national  RBF  assessment  without  waiting  for  the  P4P  impact  evaluation  results  in  a  rush  to  access  Trust  Funds  

Content   Content  • Specific  design  features  to  be  potentially  informed  

by  several  experiences,  including  from  Pwani  pilot  impact  evaluation  findings,  Cordaid  PBF  design,  as  well  as  from  Rwanda,  Kenya,  Zambia,  Argentina;  but  also  with  a  view  towards  making  RBF  an  integral  part  of  the  Health  Financing  Strategy.  

• The  decision  to  pilot  RBF  model  in  a  resource  constrained  district)  driven  in  part  by  impact  evaluation  findings,  general  concerns  about  replicability  of  Pwani  circumstances  (closer  to  Dar  es  Salaam  for  most  part,  favoured  in  other  ways),  and  the  resource-­‐constrained  concern  voiced  loudly  by  DFID  who  were  supporting  the  HRITF  at  the  time.  

 

Processes   Processes  • Multistakeholder  National  RBF  assessment  team  

(including  HBF  partner,  consultant  and  MoHSW)  towards  recommendations  for  a  national  RBF  programme  as  part  of  the  envisioned  Health  Financing  Strategy;  the  RBF  assessment  team  served  a  dual  purpose  (for  RBF  and  HFS),  but  was  largely  rejected  as  the  way  forward.  

• National  RBF  Task  Force  team  put  in  place,  engaged  in  RBF  design  development  process  

• A  weak  RBF  assessment  report,  to  be  considered  as  part  of  a  Health  Financing  Options  paper.    

   

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3.2.6 Phase   VI:   the   results   based   financing   national   design   and   early   scale   up  plans,  2014-­‐2015    

“……actually   I   can   see   that   it   is   xxxxx,   from   the   Pwani   pilot   design….he   has   been   a  national  champion  for  this.  He  is  the  health  specialist  at  the  WB  but  he  has  worked  for  CHAI  and  Ifakara  and  also  he  was  here  working  as  the  head  of  the  hospital  reform.  He  is  the  one  who   introduced  the  reforms  here….  and  as   long  as  P4P  and  RBF   is   involved  he  has  been  there  all  the  way  and  has  been  supportive  always…”  RBF  coordinator.  

 

a. The  National  RBF  Design    

The  RBF  design   is  an  extension  of  what  was  being  proposed  towards  the  end  of   the  Pilot,  with   some   new   additions,   presumably   from   the   international   experience,   and   from   the  Cordaid  PBF  model.   It   is  a  gradual  shift  to  output  based  financing  and  needs  to  be  viewed  within  the  context  of  the  Health  Financing  Strategy  in  this  current  phase,  even  if  it’s  origins  may  be  have  been  separate  (see  Table  13).    

According  to  the  present  RBF  coordinator  who  was  once  the  deputy  Pwani  P4P  coordinator,  the  evaluation  findings  were  of  use  and  taken  into  consideration,  in  particular  in  informing  specific  design   features   (see   following  section  F  on  The  RBF  Design).  According   to   the  RBF  coordinator,   “P4P   informed   the   indicators   for   the   national   design,   we   included   Pwani  indicators  and  we  added  a  few  more”.  The  decision  to  broaden  the  planned  RBF  package  of  incentivised  services  and  for  example,  include  an  indicator  for  general  outpatient  visits,  was  to  prevent  the  evaluation  evidence  of  reduction  of  the  use  of  non  targeted  services  in  the  dispensaries  and  possible  inadvertent  effects  on  non-­‐incentivised  services.  Though  some  of  the   decisions   are   also   being   made   in   “the   hope   that   by   including   some   of   those   other  conditions,   for   example,  malaria,   that  we  might   have  more   leverage   in   trying   to   channel  support  from  funders  like  the  Global  Fund  through  an  RBF  mechanism  if  they  could  be  clearly  seen  as  buying  indicators  for  their  designated  area.  While  we  could  still  be  harmonizing  or  aligning  some  of  the  funding  channels”.    

The  Pwani  experience  highlighted   the  need   for  expanding   the  scope  beyond  RMNCH  only  and  cover  other  service  areas;  include  strengthening  the  capacity  of  the  health  system  and  health  facilities;  include  incentives  for  improving  services  as  well  as  for  health  workers;  and  to   be   integrated  within   the   GoT   system.   It   has  moved   away   from   incentivizing   individual  health  workers  to  incentivizing  facilities.    

 

 

 

 

 

 

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Table  13:  Key  design  features  –  Pwani  P4P  pilot,  national  RBF  programme     Pwani  P4P  Pilot   National  RBF  programme  Focus   Increase  coverage  of  RCH  services   Increase  coverage  and  quality  of  a  range  

of  PHC  services  beyond  RCH  care.  Improve  coverage  and  equity  in  use,  as  well  as  the  quality  and  efficiency  of  care  –  especially  among  primary  care  facilities,  and  accountability  and  responsiveness.    

Indicators   8-­‐10  RCH  indicator  targets  focused  on  quantity  (pending  on  level  of  care;  e.g.  institutional  delivery;  postnatal  care  within  7  days  of  delivery)  or  for  care  provided  during  a  service  (e.g.  two  doses  of  Intermittent  presumptive  treatment  (IPT)  for  malaria  during  antenatal  care  (ANC);  for  partogram  completion,  maternal  and  neonatal  death  audits  and  timely  submission  of  HMIS  reports).  6  indicators  for  council  health  managers,  and  6  for  regional  health  managers  

16  quantity  indicators  for  dispensaries  and  health  centres53;  3  CHW  indicators;  for  the  present,  district  hospitals  will  only  be  assessed  for  quality  indicators54  Quality  assessments  -­‐  18  areas  for  dispensary55;  26  areas  for  district  hospital  and  health  centres56;  12,  10  &  3  areas  for  council  &  regional  health  managers  &  for  internal  verification  teams  assessment,  respectively.  

Inclusiveness   Not  addressed   Indicators  for  providing  services  delivered  to  poor  

Payment   Paying  for  targets;  approx.  75%  for  health  workers,  25%  for  facility  improvement  

 

Fee  for  service  reimbursement  i.e.  paying  for  each  service  that  is  being  delivered  (approx.  75%    for  facility  improvement,  25%  for  health  workers)  

Institutional  Setup  

Fundholder:  NHIF    Purchaser:  MoHSW  Provider:  Health  Facilities,  council  and  regional  managers  Internal  Verification:  Regional  Certification  Committee  to  certify  facility  results,  National  Verification  Committee  to  authorise  NHIF  to  make  payments;  Independent  Verifier  (spot  checks):  NGOs/  Research  Institution/  External  consultant    No  clear  separation  of  functions  with  MoHSW  and  CHAI  as  two  key  actors.  

Fund  holder:    MoFEA  via  MoHSW  Regulator:    MoHSW  Purchaser:    National  Health  Insurance  Fund  Provider:  Health  facilities57,  council  and  regional  health  managers;  MSD    Facilitator:  PMO-­‐RALG  Verification:  internal  by  regional  team/Internal  Auditor  General;  counter  verification  by  Central  Auditor  General  (sample  of  reports)    No  clear  separation  of  functions  with  funds  being  channelled  via  MoHSW      

Source:  MoHSW  2011,  2012,  undated,  2015  

                                                                                                                         53  RCH  indicators,  including  outpatient  visits,  nutrition,  family  planning  and  HIV/AIDS/TB;  54  Diagnosis  of  chronic  conditions  such  as  cervical  cancer,  hypertension  and  diabetes  will  be  included  as  targets  when  they  are  incorporated  in  the  HMIS  55  Including  water,  hygiene  &  sanitation,,  waste  management,  maternal  &  perinatal  death  audits,  community  health  fund,  patient  satisfaction  56  Including  water  and  sanitation,  obstetric  emergencies,  partogram,  sterilisation,  TB  services  (and  including  patient  satisfaction)  57  All  public  facilities  meeting  readiness  criteria,  selected  private,  and  faith  based  organisations  where  there  are  service  gaps/  service  agreements  for  selected  services  

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There  is  an  issue  with  the  Design.  Development  Partners  committed  funds  on  the  basis  of  an  agreed   institutional   structure   with   the   Ministry   of   Finance   being   the   fund   holder   and  channeling   the   funds   directly   to   the   health   facilities   and   not   even   passing   through   the  Councils.  But  more  recently  it  has  been  revealed  that  this  will  not  be  the  case  and  funds  will  be  channeled  via  the  MoHSW.  The  practice  of  Ministry  of  Finance  channeling  performance  funds  directly  to  facility  bank  accounts  is  reportedly  contrary  to  audit  systems  in  place  that  are   aligned  with  decentralization;   though   for   the   education   sector,   there   is   a   Presidential  Decree   to   allow   direct   funding   of   secondary   schools.   According   to   one   key   informant,   a  missed  opportunity:  “the  pilot  could  have  been  be  used  to  pilot  something  innovative!”,  [KI  17]  

a. Evaluation  of  RBF  in  Tanzania  

The  Ifakara  Health  Institute  in  collaboration  with  the  London  School  of  Hygiene  and  Tropical  Medicine,  and  Chr.  Michelsen  Institute  (Norway),  has  been  granted  partial  funding  from  the  Research  Council  of  Norway  to  do  a   follow  up  study   in  Pwani  and  an   impact,  process  and  economic  evaluation  of  the  national  roll  out  of  RBF  in  Tanzania.  The  evaluation  will  assess  the       impacts  of  RBF   in   several   areas,   including  on:   accessibility   and  utilization  of   primary  health   care   services;   quality   of   health   services;   productivity   and   efficiency   of   service  delivery;   equitable   access   to   health   care;   the   quality   and   use   of   data   for   evidence   based  decision  making;   accountability   and   responsiveness   of   health  management   teams;   health  outcomes;   the  cost-­‐effectiveness  of  RBF;   the  causal  pathways   through  which  RBF   leads   to  outcome  effects;  and  the  effects  on  health  workers  and  the  role  of  context.  

b. The  process  of  finalising  the  RBF  design    

Consultations   with   key   stakeholder   groups   such   as   the   health   basket   fund   partners,   in  particular  the  WB  have  been  underway  since  2014,  as  the  MoHSW  continued  to  refine  and  finalise  key  RBF  design  elements,  as  well  as  plans  for  scaling  up  the  intervention.      

The  World  Bank’s  active  engagement  as  a  potential  major  funder  was  evident  from  January  2014   onwards  when   they   ‘started   funding   the   preparation   of   this   RBF  …   .and   one   of   the  requirements   to   the   government   at   that   time  was   that   they   had   to   put   an   RBF   team’   in  place,  reported  a  key  informant  [KI  17].      

To   most   health   basket   fund   partners   and   representatives   from   the   MoHSW,   the   design  process  has   since   the  beginning  of  2015  become   internal   to   the  World  Bank  and   the  RBF  task  team  which  was  established  in  the  ministry,  at  times  including  Prime  Ministers  Office,  Regional  and  Local  Government:  “It’s  too  much  driven  by  the  philosophy  of  the  WB  and  the  US”     [KI   6].  More   recently   the   team  has   been   receiving   technical   (capacity   development)  support  from  Swiss  Development  and  Cooporation  and  P4H.  

Initially   there   seemed   to   be   a   lot   of   interest   in   involving   the   Health   Financing   technical  working  group  in  terms  of  ensuring  the  linkage  to  the  financing  strategy  development  and  seeing  RBF  as  a  purchasing  mechanism  of  quality  services  within  health  financing.  The  task  force  “met  regularly”  at  first  but  over  time,  it  has  become  ‘more  a  closed  process  with  the  World  Bank  being  very  much  the  driver’.  The  RBF  coordinator   is  a  member  of  the  HF-­‐TWG  whose  members  are  supposed  to  get  regular  updates,  and  be  able  to  input,  but  for  various  reasons   (including   the   RBF   team   being   away)   these   updates   have   not   been   as   regular   as  

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envisaged:     ‘…there   is   a   feeling   that   those  members   of   the   task   force  who  were   once   all  engaged   are   less   engaged   now   because   it   has   become   more   of   a   World   Bank   project  preparation  process  which  is  not  as  open  as  it  used  to  be”,  [KI  10].  

Concerns   prevail   among   some   key   stakeholders   on   lack   of   openness   and   circulation   of  information;   but   also   not   knowing   what   is   going   on   and   how   to   plan   for   their   own  involvement  and  support  to  the  Sector.  For  example,  health  basket  funders  have  “not  seen  what  they  [WB]  are  doing  in  Shinyanga  [referring  to  the  Kishapu  pilot]……we  know  that  they  [WB]  want  to  have  a  results  funded  approach  in  the  [Basket]  MoU,  but   information  is  also  limited,”   [KI   6].   It   is   only   very   recent   when   partners   and   national   stakeholders   were  informed  of  the  scale  up  plans  with  an  update  on  the  Kishapu  pilot  58.      

The   design   document   has   now   been   shared  with   the   Health   Financing   technical   working  group  as  well  as  the  recently  incepted  RBF  Steering  Committee.59  

According   to   one   key   informant   (KI   3),   while   the   Pwani   Pilot   ‘was   operated   externally  [CHAI]’,   with   the   RBF   design   process,   ‘the   government   is   taking   the   lead   [with   the   RBF  design  process]’.  But  as  noted  by  another  key  informant  [KI  5],  “with  World  Bank  and  USAID  involvement,   there   is  much  more  “hands  on  guidance”  given  to   the  RBF  team  which   if  not  carefully  managed  may  lead  to  a  more  donor  driven  process  than  it  was  for  Pwani  P4P”.  

Commented  the  World  Bank  representative:  ‘I  heard  that  there  are  other  partners  who  are  interested  to  support  it  [RBF].  We’d  rather  that  they  do  it  too  so  that  it  becomes  something  that  is  owned  by  a  lot  of  people’.  According  to  the  WB,  they  have  been  engaged  in  various  RBF  projects   and  modalities   and  have   learnt  many   lessons   in   the  process.   Their   aim   is   to  provide   technical   support  where  needed,   share   this   knowledge  and   facilitate   the  process.  Tanzania  can  make  their  own  mistakes  but  not  to  repeat  those  that  have  already  been  made  by  others.  Also  “we  need  to  be  pragmatic”.  Tanzania  is  a  big  country.  With  a  population  of  over  49  million  people  and  diversity  in  social,  cultural  and  economic  groups,  there  is  no  one  size  fits  all  solution.  Implementation  is  going  to  be  very  context  specific.  ‘There  is  no  100%  guarantee  that  it  will  work’   in  every  district  for  example,  though  ‘there  is  a  lot  of  evidence  that  says  it  has  worked  in  most  cases  so  there  is  no  reason  why  it  shouldn’t.”  Nevertheless,    ‘you  don’t  want  to  go  nationwide  with  a  program  that  has  actually  not  been  tested  fully  in  its  new  design…….  if  we  see  down  the  road  that  this   is  working,  then  yes  let  the  basket  go  and   roll   it   out   so   everything   comes   into   the   same  pot  and  goes   that  direction.’   If   there   is  funding   for   that   in   the   Basket   –   the   intention   is   to   see   RBF   as   a   precursor   to   active  purchasing   through   insurance.   On   the   whole,   there   is   a   consensus   among   health   basket  fund   partners   that   performance   matters,   but   as   noted   by   the   WB   representative   ‘the  question   is   do   you  have   to   use   facility   based  performance,   local   performance,   or   national  performance…it’s   more   a   matter   of   modalities,   and   we   have   to   admit   that   RBF   is   very  intensive…”.  Operationalisation  of  RBF  remains  a  challenge.                                                                                                                              58  Current  scale  up  plans  including  preliminary  results  and  implementation  challenges  encountered  during  the  ongoing  Kishapu  pre-­‐pilot  that  began  in  April  2015  (see  later  section  for  details),  as  well  as  links  to  HSSPIV  and  the  BRN  initiative  have  been  very  recently  discussed  in  the  HF-­‐TWG  (Aug  28,  2015),  nutrition-­‐DPG  (Aug  19,  2015)  and  the  nutrition  multisectoral  alliance  meeting  (Sept  4,  2015).  59  The  Steering  Committee    met  in  August  2015  for  the  first  time  and  one  task  to  prepare  was  the  SC  guidelines  (i.e.  What  it  does,  who  the  members  are,  how  it  will  work/  governance  structure).  Official  documents  are  being  worked  on  describing  the  composition,  roles  and  responsibilities.  Membership  to  the  SC  is  composed  of  key  actors  of  the  RBF:  MoHSW  Chair,  PMORALG  Co-­‐chair,  MoFEA,  NHIF,  DPs  –  RBF  supporting  DPs  (WB,  USAID),  Basket  DPs  (SDC/P4H  focal  person),  1  private  sector  (APHTA)  rep  and  1  CSO  (SIKIKA)  rep  [KI  10].    

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The  World   Banks   Basic   Health   Service   Project   has   now   evolved   into   RBF,   “kind   of   a   free  standing  component  of  the  new  World  Bank  programme”.      

b. Scale  up  plans  and  preparations  

i. RBF  structures  

The  RBF  unit  that  has  been  established   in  the  MoHSW  is  an  expansion  of  the  existing  P4P  Pilot  Management  Team.  More  recently,  a  RBF  Steering  Committee  has  been  put   in  place,  chaired   by   the   Permanent   Secretary   from   MOHSW,   and   with   membership   of   key  stakeholders  from  the  Government,  Development  Partners,  the  private  sector  and  the  civil  society.  As  with  the  P4P  Pilot,  PMORALG  has  not  been  very  involved  in  the  RBF  process  to  date.   Even   though   three   representatives   from   PMO-­‐RALG   are   part   of   the   larger  GoT   RBF  team,  their  visibility  and  engagement  in  RBF  discussions  is  limited;  capacity  is  not  the  issue,  according   to  one  key   informant   [K5].   Further,  PMO-­‐RALG  has   its  own  RBF  unit  and   this   is  rarely  talked  about.    

ii. Scale  up  time  line    

The  options  for  phasing  and  timeline  for  the  roll  out  over  the  coming  four  years  to  end  2018  are   tentative     (see   Figure   3),   and   will   partly   depend   on   implementation   challenges  encountered  along   the  way,  as  well  available  operational,   technical  and   financial   support.  According  to  most  recent  discussions60,  the  less  well  off  five  BRN  (Big  Results  Now)61  regions  in  the  Lake/Western  Zone  –  Kigoma,  Geita,  Mwanza,  Mara,  Simiyu  are  likely  to  be  prioritized  for  RMHCH,  as  well  as  Shinyanga  and  Pwani.    Eligible  facilities  will  include  all  public  facilities  meeting  readiness  criteria  (using  the  Big  Results  Now  star  rating  tool),  and  private  and  faith  based  organisations  with  service  agreements  for  select  services.    

Star   rating   of   primary   health   facilities   has   been   recognized   as   the   flagship   for   BRN  Healthcare.  The   final   star   rating   for  any   facility   reflects   that   facility’s  performance  against  agreed  national  standards  and  norms.  These  are  standards  for  safe  and  quality  health  care,  but   also   require   performance   in   the   related   areas   of   good  management,   organization   of  services,   functional   infrastructure   and   well-­‐equipped   facilities,   client   focus   and  accountability  for  service  charters.  A  facility  needs  to  score  at  least  one  start  to  be  eligible  to  enter   into   RBF.  Under-­‐performing   health   facilities   are   expected   to   get   support   from   the  Councils  to  bring  them  up  to  the  desired  standard.  

 

 

 

 

 

                                                                                                                         60  RBF  for  Health  in  Tanzania.  MoHSW,  Health  Financing  TWG  presentation  on  28th  August  2015.  61   Big   results   now   involves   different   interventions   in   different   regions;   some   regions  will   have   programmes   to   address  health   facilities,   commodities,  human   resources  and  RMNCH,  while  other   regions  will   implement  only  a   subset  of   these  programmes.  All  components  are  highly  synergistic  with  RBF.      

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Figure  3.  RBF  phasing  and  implementation  timeline*  

 

*  Mwanza  was  recently  included  and  will  be  implemented  in  2016  alongside  Pwani.  

iii. The  Kishapu  District  pre-­‐Pilot  (in  Shinyanga  Region)  

The  phased  introduction  of  the  national  RBF  intervention  started  in  April  2015,  with  a  pilot  in  Kishapu  district  in  Shinyanga  region.  Kishapu  district  has  a  population  of  272000.    

Unlike   the   Pwani   Pilot   which   was   under   tremendous   pressure   to   implement   in   a   short  period  of   time  whilst   simultaneously  putting   in  place  a  monthly   routine   reporting  system,  adequate  preparatory  time  has  been  given  to  Shinyanga.  Discussions  began  in  2013  around  when   the   Health   Results   Trust   Fund   got   involved.   There   have   been   countless   meetings,  ongoing  preparations  and  resource  mobilisation.  

A  brief  preliminary  visit  to  Kishapu  district  in  April/May  2015  revealed  that  following  several  World   Bank   supported   preparatory   assessment   visits   by   MoHSW   and   Bank   consultants,  interviewed  health  workers  and  their  managers  at  district  and  regional  levels  were  aware  of  the  RBF  intervention  (then  very  much  thought  of  as  a  World  Bank  project)  and  the  intended  Pilot   in   their   district   (see   Annex   B).   However,   district   managers   and   health   providers  appeared  to  have  received  little  information  on  the  specifics.62  All  the  same,  all  were  quite  positive  –  and  most  excited  by  the  fact  that  the  bonuses  will  be  paid  directly  to  their  facility  bank  accounts  and  that  in  collaboration  with  health  facility  governing  committees  they  will  have   authority   over   use   of   the   facility   funds.   The   overall   opinion  was   that   as   key   district  level   implementing   partners,   the   district  managers   need   to   be   kept   better   informed   and  more   involved   in  the  preparatory  and  pilot  process,  as  well  as   in  ongoing  decision  making                                                                                                                            62  More  recently  in  mid-­‐May,  MoHSW/WB  team  reportedly  carried  out  a  two  days  RBF  sensitisation  of  councillors  and  Community  Health  Management  Team  (CHMT)  member  in  mid-­‐May  (before  this  field  visit)    

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Key: •  Regions with HRH distribution, HF,

commodities & RMNCH initiatives

•  Regions with HRH distribution, HF & commodities initiatives

•  Regions with HF & commodities initiatives

*assessment is done across all mainland regions

Dar Es Salaam

Mara

Kilimanjaro

Manyara Tanga

Lindi

Mtwara Ruvuma

Iringa Morogoro

Pwani

Dodoma Singida

Rukwa Mbeya

Kigoma Tabora

Shinyanga

Kagera Mwanza

Geita Simiyu Arusha

Katavi

Njombe

Harmonising the implementation plans at the most under-served regions

Source(s): BRN Healthcare Lab 2014

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processes.  Regional  and  district  councils,  as  well  as  health  workers  are  yet  to  be  sensitized  towards   creating   a   sense   of   shared   commitment   among   stakeholders.   National   level  consultations  are  still  ongoing.  

Information  shared  during  a  recent  health  financing  technical  group  meeting63  suggests  that  the  Pilot  is  well  underway.  Several  preparatory  activities  have  been  accomplished  (see  Table  14).   In  a  follow-­‐up  meeting64,  the  RBF  coordinator  noted  her  satisfaction  with  the  support  received   from   a   Kishapu-­‐based   non-­‐governmental   organisation   during   the   verification  phase.  The  RBF  coordinator  also  expressed  some  concern  on  how  health  providers  will  react  to  their  deflated  motivational  earnings  as  a  result  of  poor  quality  assessment  results  which  were   mainly   a   result   of   poor   infrastructure,   well   beyond   their   control   at   present.   It   is  noteworthy   that   most   of   the   enrolled   facilities   had   only   scored   a   single   star   during   the  readiness  assessment.  There  are  plans  to  provide  all  such  facilities  in  Kishapu  district65  with  seed  funding  (about  Tshs  10,000,000  each)  for  facility  improvement  and  it  is  hoped  that  this  will  help   them  address  some  fundamental  constraints,  enable   them  to  deliver  a  minimum  quality   of   care   and   perhaps   score   better   in   the   next   round.   There   follow   some   equity  concerns  (KI  10):  only  those  facilities  with  one  star  will  be  injected  with  funds  to  lift  them  up  to  a  higher  star  grading;  facilities   in  dilapidated  conditions  that  do  not  meet  the  minimum  criteria  for  RBF  registration  will  altogether  fail  to  receive  RBF  or  BRN  support.  The  onus  is  on  the  local  government  authorities  to  find  funds  to  ensure  that  all  facilities  meet  the  one  star  minimum  threshold.  The  challenge  will  be  that  poorer  councils  are  arguably  more  likely  to  have  more   facilities   in   poorer   condition,   and   the  weighted  Basket   formula   and   funding   is  insufficient  to  redress  this.    

Figure  4.  RBF  invoicing  and  payments66  

 

Source:  MoHSW,  undated  

 

 

                                                                                                                           63  RBF  for  Health  in  Tanzania.  MoHSW,  Health  Financing  TWG  presentation  on  28th  August  2015.  64  August  19,  2015  65  It  is  not  clear  if  this  strategy  of  providing  “seed  funds”  is  just  for  facilities  in  Kishapu  district  or  if  this  is  the  intention  in  all  pilot  districts  as  there  is  a  scale-­‐up.  66  Note:  funds  are  no  longer  flowing  from  MoFEA  to  health  facilities  as  originally  agreed;  MoFEA  is  channeling  funding  through  MoHSW.  

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Table  14.  An  update  on  Kishapu  pre-­‐Pilot  (August  2015).  

Activities  accomplished  • Trainings  and  orientation  sessions  well  attended  (attendance  rate  of  85-­‐100%)  • BRN  Star  rating  readiness  assessment  of  51  facilities:  five  got  ‘0’  stars,  2  with  ‘2’  stars  each  and  

the  rest  got  a  single  star  • 46  health  facilities  enrolled  in  RBF  in  April  2015  (41  dispensaries  &  4  health  centres  in  Kishapu  

district;  and  1  district  hospital  in  Kahama  district)  • Signed  performance  agreements  between  providers  and  purchasers    • Verification  of  1st  quarter  of  implementation  (April  to  June  2015)    • Integration  of  RBF  invoicing  and  data  analysis  component  into  DHIS2    • Data  entry  accomplished  and  the  approval  process  by  the  regional  RBF  committee  was  about  to  

take  place.  Quality  Assessment  Results  • 6  facilities  scored  between  60-­‐68%  • 14  between  50-­‐59%  • 16  between  40-­‐49%  • 9  got  less  than  40%  • Kahama  district  hospital  got  46.4%  • Kishapu  CHMT  got  59.1%  Emerging  challenges  for  scale  up    • Low  performance  earnings  due  to  poor  quality  assessment  scores  mainly  due  to  weak  

infrastructure  (e.g.  no  water,  electricity),  with  implications  for  HW  motivation.  • Feasibility  of  completing  the  verification  process  and  ensure  timely  flow  of  funds  to  facilities,  

within  60  days  after  the  end  of  the  quarter  (see  Figure  8).  • Adequate  capacity  for  a  standardised  approach  to  star  rating  assessments  (linked  to  capacity?)  • Timely  flow  of  seed  funds  to  facilities  to  address  immediate  system  constraints  (eligibility  

restricted  to  those  scoring  a  single  star  in  star  rating  assessments    -­‐  by  October  1,  2015,  qualifying  facilities  in  Kishapu  had  yet  to  receive  their  “seed”  funds)  

• Equity  implications  of  star  rating  criteria  with  respect  to  “seed”  funds  eligibility  criteria  as  opposed  to  those  not  meeting  the  star  rating  criteria  at  all  and  therefore  not  being  registered  in  the  RBF  initiative  

• Equity  implications  of  poorer  councils  more  likely  to  have  poorer  facilities  and  not  in  a  position  to  ensure  that  all  facilities  meet  the  one  star  minimum  threshold.  

 

iv. Financing  the  national  programme  

Funding  for  the  national  programme  is  under  discussion.  In  February  2015,  the  World  Bank  called   a   meeting   of   the   Health   Financing   and   the   Maternal   and   child   health   technical  working   groups   to   introduce   the   Global   Financing   Facility   (GFF)67   for   every   woman   and  every   child:   a   potential   funding  modality   to   support   Big   Results   Now   (BRN)   priorities.   In  March   2015,   a   follow   up   GFF   meeting   for   key   stakeholders     (MoHSW,   development  partners,   researchers   and   the   civil   society)  was   facilitated   by   consultants   from   the  World  Bank  (Washington  DC),  WHO  (Geneva)  and  UNFPA  (New  York).    

                                                                                                                           

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The  GFF  is  regarded  a  continuum  of  the  Health  Results  Innovation  Trust  Fund  which  is  now  over,   “implying   the   ongoing   RBF   program   will   be   expanded   and   will   be   cofunded   by   a  number  of  partners  in  the  GFF  Investors,”  [KI  19].  

Most   recent   estimates   suggest   that,   World   Bank   support   to   the   national   RBF   initiative  amounts   to  a   total  of  USD  106.16  million  over   five  years   that   includes  $30m  from  an   IDA  credit,   46m   from   USAID   administered   through   a   single   donor   trust   fund,   20m   from   the  Global  Financing  Facility  Multidonor  Trust  Fund  and  10m  from  Power  of  Nutrition  through  the  Achieving  Nutrition  Impact  at  Scale  (ANIS)  Trust.  In  addition,  several  partners  including  GIZ   and   the   Swiss   Agency   for   Development   and   Cooperation   are   providing   technical  assistance  68.  

Most  interviewed  stakeholders  expressed  their  concern  regarding  the  financial  sustainability  of  the  RBF   initiative,  noting  that  there   is  no  shortage  of  technical  support  (at   least  for  the  present).   As   noted   by   one   key   informant   [KI   10]   Tanzania’s   health   sector   is   significantly  reliant  on  external  support  and  “this  is  already  an  unpredictable  future  because  donors  are  also   depending   on   the   state   of   their   economies”.   At   the   same   time   funding   facilities   are  being  put  in  place  and  “usually  the  funds”  flow  with  it;  hence  suddenly  “GFF  came  up  out  of  nowhere  and  GFF  has  a  target  to  link  up  with  RBF”.  So  there  is  also  some  recognition  that  if  the  pilot  shows  success  there  may  be  other  willing  partners  wanting  to  support  the  national  initiative.    

v. Performance  based  approach  to  Health  Basket  Fund  

On  August  29,  2015,  the  Government  of  Tanzania  and  several  health  basket  fund  partners  (Denmark,   Ireland,  UNFPA,  UNICEF   (United  Nations  Children’s   Fund)  and   the  World  Bank)  signed  a  new  Memorandum  of  Understanding  (MoU).69  An  estimated  US$  250m  is  expected  to  be  distributed  through  the  Health  Basket  Fund  over  the  next  5  years;  TShs  79.9  billion  has  been   committed   for   2015/16,  with   TShs  65  billion   (81%  of   the   funding)   to  be   transferred  directly   to   the   local   government   authorities   for   implementation   of   primary   healthcare  services.   Other   development   partners   may   join   in   the   near   future.   As   per   previous   HBF  

                                                                                                                         68  RBF  for  Health  in  Tanzania.  MoHSW,  Health  Financing  TWG  presentation  on  28th  August  2015.  69  Press  Release.  29  August  2015.  Government  of  Tanzania  and  Development  Partners  sign  new  five  year  commitment  in  the  health  sector  

The  Global  Financing  Facility  (GFF)  was  first  announced  at  the  June/July  2014  UN  General  Assembly  by  World  Bank  Group  President  Jim  Yong  Kim,  UN  Secretary-­‐General  Ban  Ki-­‐moon,  Prime  Minister  Stephen  Harper  of  Canada  and  Prime  Minister  Erna  Solberg  of  Norway,  as  a  key  financing  platform  of  the  UN  Secretary-­‐General’s  Every  Woman  Every  Child  Global  Strategy.  It  was  by  launched  by  the  World  Bank  Group  and  her  partners  at  the  Third  International  Financing  for  Development  Conference  in  July  2015  in  Addis  Ababa.  Norway,  Canada,  Bill  and  Melinda  Gates  Foundation,  and  to  some  degree  the  US  and  Japan  are  supporting  the  GFF  Trust  Fund.  The  GFF  Facility  has  a  number  of  investors,  including  Gavi,  The  Global  Fund,  UNFPA,  UNICEF,  WHO,  etc.  Tanzania  is  amongst  the  first  four  countries  to  join  the  GFF;  the  remaining  three  being  the  Democratic  Republic  of  Congo,  Ethiopia  and  Kenya.      http://www.worldbank.org/en/topic/health/brief/global-­‐financing-­‐facility-­‐in-­‐support-­‐of-­‐every-­‐woman-­‐every-­‐child  

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arrangement,   funds  will   be   equitably   distributed   to   Local   Government   Authorities,   taking  into  consideration  population  size,  poverty  status,  health  need  and  land  area,  to  ensure  that  rural   and   underserved   populations   are   reached   with   affordable,   quality   and   necessary  health  services.  Funds  will  also  be  allocated  to  Ministry  of  Health  and  Social  Welfare,  Prime  Minister’s   Office,   Regional   Administration   and   Local   Government   and   Regional   Health  Management  Teams.    

A  significant  new  feature  of  the  arrangement  is  the  introduction  of  a  performance  tranche  financing  approach.  According  to  a  key  informant,  the  HB  now  will  be  50%  of  base  tranche  and  50%  on  performance  of  the  council  which  will  be  based  on  a  balanced  score  card  of  12  indicators,   some   of   which   will   be   the   same   as   the   RBF   indicators,   and   some   which   are  different.  Over  time,  there  needs  to  be  an  alignment  of  the  two  performance  mechanisms  within  the  Basket  (i.e.  the  Council  and  Health  facility)  and  eventually  a  common  verification  system,  if  this  is  the  way  forward  for  the  Basket.  Another  possible  option  as  pointed  out  by  one  key  informant  [KI  17],   is  to  have  the  Basket  fund  the  Single  National  Health  Insurance  for   the   indigent   (effecting   the   exemption   scheme),   with   active   purchasing   and   quality  assessment  on   the  provider  side.  The  challenge   for  Health  Basket  Partners  at   this  point   is  that  they  need  to  support  the  whole  country,  not  just  pilot  regions.  The  Agreement  for  the  Health  Basket  Fund  has  a  clause  about  piloting  Direct  Facility  Funding  within   this   financial  year.  

The   World   Bank,   “the   most   influential   financial   institution   in   the   world”,   is   the   current  coordinator   of   the  Health   Basket   Fund.   It   is   a  moot   point   as   to  whether   the  World   Bank  accurately  represents  Health  Basket  Partner  views  on  many   issues.  Even  though  all  Health  Basket  fund  partners  have  a  voice,  the  World  Bank  contributes  to  some  40%  of  the  health  basket  and  they  have  a    “big  say”  in  the  direction  of  where  and  how  the  HBF  develop:  “90%  of  the  decision  is  influenced  by  the  World  Bank  directly  or  indirectly;  there  are  many  ways  of  manipulating  the  truth”  [KI  6].    

Nevertheless,   the   HBF   partners   and   the   Bank   will   have   to   eventually   agree   on   the   way  forward  with   their   ‘twin  goals’  of  equity  and  performance,  not  withstanding   the   fact   that  the  ideology  of  the  World  Bank  is  very  different  from  that  of  some  of  the  bilateral  donors:  “clearly  we  are  different  and  have  very  different  perception  of  fairness,  equity,  distribution  system  including  health  financing  and  WHO  has  to  PAY  for  WHAT,  WHEN  and  WHERE,”  [KI  6].  Much  more  importantly,  MoHSW  needs  to  assert  some  leadership  over  her  priorities  –  one   should   not   forget   that   the   World   Bank   support   to   the   Basket   is   a   loan   to   the  Government.  

The  element  of  half  of  an  already  shrinking  basket  being  performance  based  may  well  result  in  an  absolute  reduction  of  Health  Basket  Fund  support  –  a  cause  for  concern  among  several  national  representatives.    

   

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Table  15.  Shifting  influence  and  position  of  key  actors  from  Phase  I  to  Phase  VI  of  the  RBF  policy  formulation  process  

Phase Support Non Mobilised

Opposed

High Medium Low Low Medium High

I&II: Dec 2006 – mid 2007

GoN-PMO GoT-PO

HBF* WB UNFPA

H

Leve

l of

Infl

uen

ce

BBA M MoHSW-DPP IHI

Norad RNE-Tz MoHSW (some), central & line ministries, CSOs, researchers

L

III: 2007-2009

GoN-PMO GoT-PO

World Bank? HBF** Norad, USAID (towards the end)

H

Norad (beginning), MoHSW-DPP, USAID/BBA

Norwegian consultants, CMI

M

IHI, Cordaid RNE-Tz, Health providers & their managers (some)

MoHSW (Rest)

L

IV&V: 2010-2013

GoN/Norad/RNE-Tz GoT

World Bank?

H

BBA/USAID CHAI

HBF** M

NHIF, Wajibika, Cordaid, Pwani HPs & managers, MoHSW (P4P-Coord), HF-TWG, HMIS, DPP), P4H

IHI, LSHTM, CMI

P4P Advisory Comm Members (some)

Community MoHSW (some) PMO_RALG Researchers (some) CSOs (some)

MoHSW (some) Researchers (some)

L

VI: 2014-2015

WB, USAID, Norway (Global), GoT-PO

Health providers

H

UNFPA, WHO, UNICEF, Power of Nutrition, GFF, DANIDA, IA

LSHTM (E4A), Mama Ye Tanzania

M

MoHSW –RBF unit, RBF steering comm, HF-TWG, MNCH-TWG, DPM, TFNC, MoFEA, RMOs, DPG-Nutrition, SDC, P4H network, Cordaid

HBF (some) IHI, LSHTM, CMI,

CHAI, Researchers, CSOs, Community, MoHSW (Rest), PMO-RALG, Norad, RNE-Tz

L

High Medium Low Low Medium High

Supportive Not Mobilised

Opposed

*DANIDA, SDC; ** DANIDA, SDC, Irish Aid; H-High, M-Medium, L-Low

Source:  Forcefield  Matrix,  Onoka  et  al  2014,  p8;  Varvasovszky  &  Brugha  2000  

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c. Alignment  of  RBF  with  national  plans  and  strategies  

RBF   is   viewed   as   a   integrated   but   transitional   health   financing   intervention   with   the  potential   to  boost   health   system   functioning   towards  better   quality   and  uptake  of   health  care,   and   facilitate   the  move   towards   universal   health   coverage   [KI   10].   Transitional   until  the   single  national  health   insurer   is  operational,   as  once  you  have  a   functioning  universal  insurer,   RBF   should   not   be   needed   as   a   separate   intervention   but   be   integrated   into   a  performance   contracting   system   via   the   insurer.70   The   approach   will   however   require  additional  financing  to  make  it  work  and  provide  full  subsidies.      

The   integration   of   RBF   into   the   District   Health   Information   System   and   linkages  with   Big  Results  Now  initiatives  is  reportedly  underway.  BRN  priorities  are  also  being  integrated  into  the  fourth  Health  Sector  Strategic  Plan  (HSSPIV)  which  is  costed  using  the  OneHealth  model  or   tool.   BRN-­‐related   activities   are   reportedly   being   incorporated   into   the   Council  Comprehensive  Health  Plan’s,   for   funding   through   the   routine/existing   sources  –  with   the  possible  exception  of  activities  funded  by  UNFPA.    

The   Health   Basket   Fund   is   aligned   to,   and   supportive   of   the   achievement   of,   the   Fourth  Health   Sector   Strategic   Plan   (HSSP   IV)   in   line  with   its  mission  of   ‘Reaching  all  Households  with  Quality  Health  Care’,  and  Tanzania’s  programme  of  strategic  prioritisation  in  the  health  sector,  ‘Big  Results  Now’.     It  however,  remains  to  be  seen  how  the  Basket  adapts  over  the  HSSPIV  period  as  it  moves  towards  an  output  based  payment  mechanism  as  opposed  to  an  input  based  mechanism  which  the  basket  has  been  till  now  [KI  10].  

Overall,  where  there  was  quite  a  lot  of  uncertainty  earlier  this  year,  there  is  a  sense  of  plans  firming  up,  with  initiatives  being  aligned  and  key  stakeholders  coming  together  –  “RBF  has  been   accepted   and   embraced   as   a   purchasing   mechanism   or   as   one   of   the   purchasing  mechanisms  of  the  government,”  (KI  10).  Most  partners  seem  to  be  aligned  and  on  board  -­‐  a  relatively  more  supportive  RBF  landscape  (see  Tables  15  and  16).  .    

Table  16.  Phase  VI  –  Facilitators  and  Barriers  

Facilitators   Barriers  Key  actors   Key  actors  • WB  generating  a  broader  buy  in  to  the  RBF  

process  • A  national  champion  –  conversant  with  

priorities,  strengths  and  weaknesses  of  the  health  system,  involved  in  the  national  RBF  scale  up  process  from  the  first  national  design,  supportive  of  and  well  respected  by  national  players,  and  in  a  very  strategic  position  to  guide  all  RBF  key  stakeholders  towards  a  common  agenda  –  MoHSW,  the  World  Bank  and  other  health  development  partners    

• Growing  consensus  amongst  health  basket  

• A  closed  internal  process  driven  by  the  World  Bank  (with  RBF  unit);    

• RBF  task  force  and  key  stakeholders  less  engaged,  with  irregular  updates  on  the  design  process,  pilot  and  roll  out  plans  

• Limited  involvement  of  PMO-­‐RALG  (health)  in  national  level  RBF  design  process  and  implementation  plans    

• HBF  partners  aligned  and  harmonized  but  each  with  their  individual  priorities  

• Kishapu  pre-­‐pilot  district  –  inadequate  involvement  of  district  managers  during  the  early  preparatory  phase  

                                                                                                                         70  As  an  active  purchasing  mechanism,  it  will  probably  be  easier  to  align  RBF  with  the  health  financing  strategy  and  a  move  towards  insurance.  Also  because  the  proposed  purchaser  is  the  national  health  insurance  fund  and  it  would  be  ultimately  a  single  national  health  insurance.  

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partners  that  performance  matters    • RBF  coordinator  actively  involved  in  the  RBF  

design  formulation  process    • Impact  evaluation  research  consortium  (IHI-­‐

LSHTM-­‐CMI)  keen  to  addresses  the  most  relevant  policy  questions,  as  prioritized  by  MoHSW  

• Pre-­‐pilot  district  NGOs  innovative  and  supportive  during  verification  process  

• Kishapu  health  providers  very  excited  at  the  prospect  of  having  control  over  some  facility  funds  and  decision  making  process    

 

 

Context   Context  • World  Banks  Basic  Health  Service  

Programme  has  evolved  into  RBF  • Performance  Based  Basket  Fund  MoU  with  

Government  of  Tanzania  • Health  Basket  Fund  aligned  to,  and  

supportive  of  the  achievement  of,  the  Fourth  Health  Sector  Strategic  Plan  and  strategic  prioritisation  in  the  health  sector,  ‘Big  Results  Now’.    

• A  more  supportive  RBF  landscape  with  key  actors,  initiatives  and  plans  (HSSPIV,  BRN,  HFS)  aligned  with  growing  commitment  at  all  levels  of  the  system    

• Adequate  time  for  preparations  of  the  RBF  design  –  not  a  rushed  process    

• Donor  politics,  poor  national  accountability,  global  financial  constraints  and  reliance  on  external  support  

• Shrinking  Basket  with  half  of  it  being  performance  based  could  result  in  reduction  of  basket  funds  to  the  health  sector  

• Lack  of  harmonisation  of  two  performance  based  initiatives;  potential  tension  between  Basket  partners  –  the  Bank  and  bilaterals.  

• Irregular  flow  of  funds  from  central  to  local  government  to  facility  level  

• An  absence  of  incentives  in  the  Government  system  for  good  performance,  especially  at  the  central  level  

• Weak  central  level  capacity  and  leadership  to  define  changing  sectoral  priorities      

• Weak  managerial  capacity  at  central,  regional,  council  level  to  make  an  indicator  system  work  

• Weak  implementation  capacity  at  regional  and  district  level  

• Weak  central  level  capacity  and  inadequate  involvement  of  PMO-­‐RALG  (health)    

• Ineffective  governance  and  accountability  structures  -­‐  to  learn  if  pre-­‐pilot  is  being  rolled  out  as  envisaged    

• Weak  implementation  of  routine  information  systems  –  reporting,  completeness,  timeliness,  quality  

• RBF  scale  up  will  need  to  be  very  

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context  specific  and  adapt  to  the  diversity.  

• A  very  short  pre-­‐pilot  coupled  with  a  tight  timeline  for  scale-­‐up  process  –  a  rushed  process  without  adequately  identifying  and  addressing  potential  implementation  challenges.  

• Limited  operational  capacity,  as  well  as  technical  and  financial  resources  

• Most  enrolled  facilities  in  pre-­‐pilot  district  facing  considerable  infrastructural  and  systemic  constraints  affecting  their  performance  earnings:  will  limited  incentives  drive  everyone?  

• Limited  funds  for  ongoing  monitoring  and  assessment  of  implementation  challenges  

Content   Content  • An  adaptable  RBF  design  and  operational  

manual  in  place  –  incorporating  lessons  learnt  from  earlier  initiatives  (Cordaid  supported  PBF  pilot,  fist  national  design,  Pwani  P4P  pilot,  and  other  countries)    

• Incentivising  indicators  beyond  reproductive  and  child  health  services,  mix  of  qualitative  assessment  of  quantitative  achievements  

• Community  health  workers  to  benefit  from  the  incentive  scheme  

• More  incentive  funds  towards  facility  improvement;  initial  facility  upgrading  seed  funds  for  infrastructure  constrained  facilities  

 

• Final  RBF  design  not  yet  formally  approved.  

• Changes  to  institutional  set  up:  Ministry  of  Finance  is  not  the  fund  holder  (contrary  to  decentralised  structure),  of  concern  to  RBF  funders  (Kishapu  pre-­‐pilot  funds  being  channelled  via  MoHSW)  

• CHMT  indicator  for  performance  could  be  a  bit  stronger  (SL)  

• Absence  of  a  minimum  benefits  package    • Equity  implications  (star  rating  initiative)  

Processes   Processes  • MoHSW  homes  the  RBF  unit  • Final  Health  Financing  Strategy  submitted  to  

the  Cabinet  for  approval    • Tentative  plans  and  funds  for  phasing  the  

RBF  initiative  to  seven  regions  over  the  next  five  years  in  place    

• Kishapu  pre-­‐pilot  under  way  with  some  key  activities  successfully  accomplished,  identifying  early  implementation  challenges    

• Revised  PMORALG  structure  to  facilitate  RBF  implementation  (with  a  RBF  unit  in  PMO-­‐RALG  as  well  though  this  is  rarely  discussed)  

• Performance  based  Health  Basket  Fund  Memorandum  of  Understanding  with  the  Government  is  in  place  

• Final  health  financing  strategy  not  yet  approved.  

• Lack  of  alignment  of  the  two  performance  mechanisms  within  the  Basket  (i.e.  the  Council  and  Health  facility)  and  parallel  verification  systems.  

• Cost  (not  known)  and  feasibility  of  carrying  out  the  verification  processes  and  timeliness  of  payments  

• Some  functions  maybe  duplicated  between  PMO-­‐RALG  Health  and  MoHSW,  which  will  be  confusing  

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4.  Discussion    

 ‘…we  think  the  roll  out  is  still  not  the  end.  What  we  really  think  is  the  end  is  when  it  [RBF]  becomes  the  way  that  the  government  finances  the  health  sector  at  the   local  level,  that  is  the  end  for  us.  That  is  when  we  will  really  truly  believe  that  change  has  happened,”  [WB  representative].  

 

Tanzania’s  RBF  policy  has  evolved  in  stages  with  different  actors  trying  to  advance  various  forms  of  performance  based  financing  mechanisms  onto  the  national  agenda  with  varying  levels  of  success  –  CORDAID,  Norway,  the  Ministry  of  Health  and  Social  Welfare,  CHAI  and  most   recently,   the  World  Bank  and  USAID.   It  has  been  what   the  President   (and   therefore  the  Government)  wanted  and  committed   to   implementing,   though   the  Ministry  of  Health  and   Social   Welfare   has   not   always   been   in   command.   The   process   has   been   supported,  albeit   in   different   ways,   by   several   stakeholders,   with   numerous   studies,   workshops   and  consultants   commissioned   or   contracted   by   Norway   and   others:   CORDAID,   the   Ifakara  Health   Institute,   and   Broad   Branch   Associates;   and   lately   by   the   health   basket   funders,  though   not   sufficiently   to   avoid   a   new  parallel  mechanism.   The   Prime  Ministers   Regional  Office   and   Local   Government   (PMO-­‐RALG),   the   body   with   the   mandate   to   oversee   the  implementation  of  health  services  at  the  local  government  level,  as  well  as  Tanzania’s  civil  society   appears   to   have   been   unusually   silent   and   detached   on   this   subject.   The  involvement   of   civil   society   organizations   on   Pwani’s   P4P   advisory   Committee  was   never  expanded   into  a  broader  national   platform   for  CSOs.   The   issue  of  poor   coordination  with  PMO-­‐RALG  is  a  perennial  one  in  the  Sector,  as  is  PMO-­‐RALG’s  low  visibility.  The  Presidential  Decree  from  December  2014  clearly  specifies  that  PMO-­‐RALG  has  the  main  responsibility  for  implementation,  and  yet   the  “responsibility”   for   the  RBF  design  and  early   implementation  plans  and  preparations  of  RBF  seems  to  rest  with  the  RBF  unit  that  is  homed  in  the  MoHSW.    

The  RBF  process  began  with  CORDAID’s  initial  attempts  at  introducing  a  performance  based  financing   model,   first   into   faith   based   facilities   and   gradually   extending   to   public   health  facilities  in  five  districts  in  rural  Tanzania.  Funding  cuts  by  the  Dutch  government  cut  short  CORDAID’s  active  involvement  in  Tanzania,  though  CORDAID/CSSC  continued  to  support  the  MoHSW   through   organizing   national   and   international   best   practice   forums   towards  discussing  an  appropriate  model  for  Tanzania;  and  has  continued  to  be  a  constant  player  in  the  national  discourse  and  design  process.    

Clearly,   initial   interest   in  experimenting  with  a  performance  based   framework   in  Tanzania  came  from  high  up,  from  the  President  of  Tanzania  and  the  Prime  Minister  of  Norway,  both  of  whom  were  motivated  by  their  evolving  interests  and  MNCH  partnerships  on  the  global  front,  with  a  willingness  to  try  out  innovative  financing  mechanisms  towards  better  health.    The  Norwegian  Prime  Minister  was  no  doubt  strongly  influenced  by  his  technical  adviser  in  this   respect.   For   Tanzania,   the   2006   Norway   Tanzania   Partnership   Initiative   (NTPI)   to  support   Tanzania’s   efforts   to   reduce   child   and   maternal   mortality   within   a   performance  incentive  framework  was  signed  amidst  a  national  context  of  high  maternal  mortality  ratios  and  against  a  backdrop  of  poor  delivery  of  quality  primary  health  care  and  strained  health  systems.   The   sector   was   increasingly   reliant   on   external   support   and   out   of   pocket  expenditures  were  on  the  increase.  The  system  was  grappling  with   low  worker  motivation  

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coupled  with   severe   shortages   of   staff,  medicines   and   supplies;   and  with   health   facilities  that   have   limited   autonomy   to   utilize   their   own   funds.   The   system   was   essentially   not  working.    The  President  was  in  search  of  alternatives  and  keen  to  introduce  a  performance-­‐based  framework  following  early  success  stories  from  Rwanda  and  Haiti.    

Despite  several  attempts  made  by  the  Norwegian  government  to  open  up  the  P4P  process  and   ensure   broad-­‐based   involvement   of   key   national   stakeholders,   health   development  partners   were   for   different   reasons   reluctant   to   support   the   process   –   including   lack   of  evidence,  concerns  with  the  capacity  of  the  system  to  follow  up  on  such  a  huge  reform,  but  also  to  do  with  donor  politics,  mistrust  (of  Norway’s  ultimate  agenda)  and  lack  of  effective  dialogue   between   Norway   and   the   development   partners   before   deciding   on   the   P4P  agenda.   Norway   then   tried   to   reach   a   compromise   with   health   basket   fund   partners   to  channel   the  money   to   support   the   national   programme   through   the   Basket   for   a   jointly  endorsed  P4P  system  but  again  this  did  not  work  out.  There  was  a  difference  of  opinions.  Given  weak  national  systems,  coupled  with  limited  operational  and  technical  capacity  at  the  local   government   level,   health   development   partners   (health   basket   funders,   as   well   as  USAID  and  Norad)   requested   for   the  MoHSW  design   to  be   first  piloted.    The  Government  was   reluctant   to   do   so   and   without   the   technical   or   financial   support   from   the   health  partners,   unsuccessfully   proceeded   with   the   national   programme.   The   P4P   policy   was  already   in   place,   albeit   unfunded.   The   concept   had   already   been   incorporated   in   third  Health  Sector  Strategic  Plan  (2009-­‐  2015)  as  a  P4P  strategy  to  improve  the  productivity  and  motivation  of  health  care  workers.  Districts  had  been  given  a  directive   to   include   the  P4P  line   item   in   the   Council   Comprehensive   Health   Plans.   There   followed   strained   relations:  between  the  development  partners,  between  RNE/Norad  and  the  Norwegian  Government,  and   with   the   Government   of   Tanzania   (&   MoHSW)   who   really   wanted   to   and   was  committed   to   implementing   the   first   national   programme,   for   various   reasons.   National  leadership  and  interests  had  been  unnecessarily  undermined.  Partner  disagreements  could  have   been   avoided  with   constructive   discussions   amongst   the   development   partners   and  with   the   Government   at   the   outset;   and   possibly   if   Norway   had   considered   relaxing   and  extending  the  time  bound  agreement.  

Then  came  the  Pwani  Pilot  in  early  2011,  a  bilateral  initiative  that  the  Norwegians  mandated  CHAI   to   support,   design   and   implement   the   Pilot.   The   Pilot   was   framed   to   inform   the  national  model.   It  was  quite   clear   from   the  outset   that   remaining  Norwegian  partnership  funds  would  only   be   sufficient   to   support   the   Pilot.   Also,  Norway  had   already  decided   to  move   out   of   Tanzania’s   health   sector.   The   main   impetus   to   proceed   with   the   Pilot   was  twofold:   the  Embassy’s   response  to  growing  pressure   from  the  Norwegian  government   to  spend   the  MCH   funds   before   the   partnership   agreement   came   to   an   end;   as   well   as   to  support  the  MoHSW  in  implementing  a  performance  based  financing  model  and  respect  the  terms  of  their  Agreement  –  a  ‘face  saving’  response  in  some  ways.  To  do  away  with  growing  donor   politics,   the   Pilot   was   funded   as   a   bilateral   project   from   outside   the   Basket.  With  minimal   resources   from   the   Government   of   Tanzania   and   limited   authority   in   the   use   of  Norwegian   funds   that   were   channeled   through   CHAI,   the   Pwani   pilot   is   viewed   among  several   national   stakeholders   as   a   largely     “donor   driven’   and   ‘donor   dependent’   process  without  ‘much  national  ownership’.  The  Pilot  was  reportedly   implemented  at  a  time  when  there  was  a  leadership  vacuum  within  the  MoHSW  and  amidst  much  tension  within  the  P4P  structure.   Lessons   from   the   Pilot   have   however   been   quite   useful   in   planning   for   the  national   RBF   scale   up   –   hence   in   many   ways,   it   achieved   its   objective   of   informing   the  

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national  model.  It  is  very  unlikely  that  there  would  have  been  any  scale  up  if  the  Pwani  pilot  had  not  been  implemented.  

Discussions   between  Norway,   the   Bank   and   USAID  were   ongoing   on   how   to   support   the  national  scale  up  process,  with  DANIDA  as  an  interested  bystander,  eager  to  learn  from  the  process  (as  they  were  supporting  the  RBF  process  in  Zanzibar).  Norwegian  government  had  the   funds,   but  was   not   interested   in   continuing   to   support   Tanzania’s   health   sector;   and  Norad  did  not  have   the   required  capacity   to   support   the   scaling  up  process.  Norway   thus  decided  to  approach  the  World  Bank  to  support  the  process  using  the  Norway/UK  funded  Health  Results  Innovation  Trust  Fund  that  was  being  managed  by  the  Bank.    

Norway  has  been  instrumental  and  a  lead  player  in  driving  the  RBF  agenda  in  health  globally  –  through  direct  bilateral  support  and  more  so  via  channeling  resources  through  the  World  Bank.  Aside  from  supporting  the  implementation  process,  knowledge  and  evidence  building,  has   also   been   a   top   priority   for   Norway.71   Thus,   the   Ifakara   Health   Institute   which   had  previously  played  a  kind  of  design  and  implementation  role  in  the  2007/2009  phase,  moved  on   to  evaluation  with   support   from  Norway:   first   the   research  consortium   (Ifakara  Health  Institute,   LSHTM   and   CMI)  was   contracted   to   support   the   impact,   process   and   economic  evaluation  of  the  Pwani  Pilot.  And  more  recently,  to  evaluate  the  national  RBF  scale  up.    

From   2014   onwards,   the   World   Bank   has   been   leading   and   supporting   the   RBF   process  towards  finalizing  the  national  design  and  the  scale  up  plans  over  the  coming  five  years.  The  World   Bank   is   strategically   poised   to   do   so   –   with   required   technical   capacity,   the   Trust  Funds  and  a  very  good  working   relationship  between   the  RBF  coordinator  and   the  Bank’s  senior  health  advisor,  the  “national  RBF  champion,  according  to  the  RBF  coordinator  (and  a  number  of  key  informants).  Starting  off  with  an  awareness  building  process  and  a  broader  buy  in  amongst  key  stakeholders,  including  MoHSW  and  line  ministries  as  well  as  the  health  development   partners,   the   Bank   has   shifted   the   narrow  project-­‐focused   P4P   agenda   to   a  national  RBF  initiative  focused  on  health  system  strengthening,  notwithstanding  the  mixed  evidence  from  the  impact  evaluation  results  that  were  released  soon  after.  Though  political,  scale   up   decisions   were   evidence-­‐informed   –   from   Pwani   Pilot,   CORDAIDs   experience   in  Rwanda,  as  well  as  other  from  lessons  learned  internationally.  Through  their  senior  health  adviser,   the   Bank   has   been   very   proactive   and   successful   in   gradually   working   its   way  towards  supporting  the  Government  of  Tanzania  (and  MoHSW)  in  aligning  national  priorities  and  plans  (BRN,  HSSPIV,  RBF,  HFS),  as  well  as  key  stakeholders  towards  a  common  agenda.  The      MoHSW  houses  the  RBF  unit,  with  strong  backing  and  support  of  the  Bank.  The  World  Bank  has   very  much  driven   the   redesign  process,   though   the  RBF   coordinator   (and   team)  have   been   closely   involved   in   the   design   formulation   process,   have   internalised   the   RBF  agenda,   incorporating   the   positive   lessons   learned   from   the   CORDAID   experience,   from  Pwani  pilot  and  from  the  neighbouring  regions.  There  has  been  space  and  time  to  define  a  national  agenda   (as  much  as  possible   for  an   initiative  overseen  by   the  most  power  global  institution,   the  World  Bank)  and  pull   together   the   first  batch  of   resources,  but   still   to   the  exclusion  of   other   stakeholders   for   a   long   time  and  with   several   delays   in   taking   the  RBF  

                                                                                                                         71   All   bilateral   and   multilateral   projects   are   followed   by   a   comprehensive   impact   evaluation   and/or   implementation  research.  Norway  has   also   initiated   and   supported   the   implementation   research   through   the  Alliance   and  Health  Policy  Systems  Research  (which  this  project  is  part  of),  and  Norway  supports  the  Community  of  Practice  on  Performance  Based  Financing  (through  ITM,  Belgium).      

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design   to   the   Board.     A   significant   contributor   to   the   health   basket,   the   Bank   has   even  managed  to  ensure  a  revised  performance-­‐based  Memorandum  of  Understanding  with  the  Government   of   Tanzania   –   a   step   towards   building   a   results   based   system   through   the  entire  system,  from  central  to  the  facility  level,  which  in  some  ways  is  quite  disconcerting  to  several  national  representatives.    

Health  basket  fund  partners  are  aligned  and  harmonized  but  towards  what  end?  RBF  seems  to  be  slowly  gaining  legitimacy  among  Health  Basket  Funders  despite  initial  disagreements  and  concerns.  Why  so?  In  theory,  it  gives  local  decision  makers  a  greater  say  over  resource  allocation;   there   has   been   a   shift   in   the   RBF   design   from   incentivizing   individual   health  workers   to   a   rounder   package   of   incentives   for   facility   performance   (of   which   health  workers   are  but   only   but   one   small   portion);   and  possibly   also  driven  by   the  World  Bank  with  its  Basket,  RBF  and  BRN  support  all  packaged  as  one  payment  for  results  programme.  The  broader  Zanzibar’s  context  of  RBF  (supported  by  DANIDA),  as  well  as  RBF  in  education  may  also  have  supported  a  shift   in  perceptions   for  RBF   in  health.  Also,  globally,   there   is  a  focus   is   on   accountability   and   an   explicit   shift   to   results   based   management   in   many  development   partner   agencies,   with   traditional   aid   modalities   (General   Budget   Support,  Basket  Funding)  coming  under  scrutiny.    

Increasingly,  there  appears  to  be  a  recognition  that  RBF  is  a  huge  reform  that  requires  to  be  very  well  designed  and  carefully  thought  out,  with  attention  to  details,  and  requires  a  buy  in  at  all   levels  of  the  system.  There  is  a  growing  consensus  that  something  needs  to  be  done  towards   addressing   existing   system   constraints,   and   RBF   needs   to   be   seen   as   part   of   the  broader  system  and  a  coherent  part  of  the  health  financing  strategy,  and  perhaps  the  World  Bank  is  uniquely  set  up  to  ‘handle  big  picture  system  change’,  but  that  the  process  needs  to  be  more  transparent  and  inclusive,  with  a  genuine  partnership  with  the  Government.  There  are   some  concerns   that   the  government   to  a   large  extent  appears   to  be  driven  or   letting  themselves  be  driven  by  external  factors,  instead  of  working  towards  a  home  grown  agenda  and  deciding  on  the  future  of  Tanzania’s  health  system.      

The  USAID   has   been   an   interested   partner   to   supporting   the   RBF   formulation   process   all  along   the   way,   but   till   very   recently   they   were   channeling   their   support   through   Broad  Branch  Associates,  an  instrumental  player  through  the  entire  process:  starting  with  the  first  meetings  held   in  Norway   towards   the  end  of  2006,   to   supporting  Norwegian  government    (and  IHI)  in  the  first  consensus  building  attempts  in  2007,  to  then  assisting  IHI,  the  MoHSW,  CHAI  and  now  the  WB/MoHSW  with  the  design  process.  With  a  more  positive  national  RBF  landscape,  the  USAID  has  stepped  up  their  direct  support  to  the  national  RBF  programme  –  and  in  fact  channeling  considerable  funds  into  the  RBF  portfolio  that  will  be  managed  by  the  World  Bank.  This  is  largely  the  result  of  concerted  effort  by  their  then  Health  System/Health  Financing   specialist   to   ensure   that   USAID   support   was   harmonized   and   aligned   with   the  Government   process,   rather   than   implementing   their   own   RBF   scheme   focused   on   their  narrow  priority  technical  areas.  

There   are   the   inevitable   challenges   of   a   government   that   receives   considerable   external  funding  (World  Bank  in  this  case)  that  shapes  national  agenda's.  The  obvious  danger  is  lack  of  an    'independent'  voice  in  'own  decision  making'  and  in  international  fora;  to  be  handed  an  agenda  which  is  not  reflective  of  local  conditions  and  needs.  The  clear  solution  to  this  is  'independence',  to  have  the  political  will  to  say  no  if  aid  is  not  essential,  but  this  is  perhaps  

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an   unrealistic   solution.   The   more   realistic   solutions   include:   first,   build   local   capacity   to  develop   policies   and   strategies   and   allow   for   a   nationally   driven   bottom   up   approach   to  both   technical   assistance   and   quality   assurance,   including   peer-­‐to-­‐peer,   as   opposed   to   a  donor   driven   top  down   type  of  model,  which   is   too   common.   Second,   spread   the   risk   by  distributing  development  assistance  more  thinly  across  Development  Partner’s,  but  not  too  thinly  to  make  transaction  costs  unbearable.  Third,  agree  on  a  framework  of  accountability  on  both  sides,  a  focus  on  mutual  accountability  –  but  that  has  been  eroding.  

In  summary,  public  policy  (choice)  is  the  product  of  a  number  of  forces,  including  dominant  power  groups,  their  values  and  interests  -­‐  as  well  as  external  pressures  from  donors  and  the  aid  theory  /  thinking  of  the  era.    All  of  the  above  was  augmented  or  affected  by  technical  /  evidence  consideration  to  a  greater  or  lesser  extent.  Development  has  never  and  will  never  be   linear  but   instead   experience   and   history   provide   lessons   that   show   how   important  contextual  thinking  and  combining  local  with  global  are  in  all  this.      

The   power   of   donors   in   a   heavily   aid   dependent   country   such   as   Tanzania   and   their  potential  for  determining  what  to  fund  is  based  on  a  complex  combination  of  factors  which  might  derail  a  country  owned   initiative.  Some  determinants  come  from  how  their   internal  bureaucracies   work   and   how   development   partners   need   to   be   accountable   to   their   tax  payers.    Others  are  based  on  the  biases  and  knowledge  base  of  the   individuals  who  sit  on  the   basket   committee   and   their   preferences.   The   dynamics  within   the   basket   committee  also  drive  decisions.    

The  initial,  radical  proposal  ran  into  trouble  because  it  did  not  have  the  support  of  the  then-­‐dominant   donor   group   (Basket   fund   partners),   nor   unqualified   policy   or   practical   support  from   those   expected   to   implement   it   (the   Norwegian   Embassy).        There   is   considerable  evolution  of  policy  environment  since  then,  a  considerable  weakening  of  the  Health  Basket  partners  as  the  dominant  donor  power,  but  of  course  for  the  World  Bank  who  coordinates  and  now  remains  the  dominant  power  behind  the  Basket.    Norway  no  longer  needs  to  be  a  solitary   champion   for   the   approach   having   effectively   brought   in   the  World   Bank   -­‐   as   a  strong  technical  ally,  with  the  power  and  credibility  to  exert  more  power  over  international  health  policy  environment  than  a  single  bilateral.    

The  benefit  of  pressure  to  introduce  P4P  was  rapid  roll  out  of  HMIS  strengthening  initiative  and  a  big  increase  in  reporting  compliance;  as  well  as  a  new  emphasis  at  council  and  facility  level  on  results,  and  accountability  for  services  delivered/targets  met.    What  was  intended  as   a   rapid   rollout   focused   intervention   has   (in   practice)   been   much   slower   and   more  incremental.  This  has  allowed  more  time  and  policy  "space"  for  various  actors  to  consider  what   they   really   wish   to   achieve   and   how.   The   trajectory   of   the   initiative   is   closely   and  clearly   linked   to   the   evolving   policy   environment,   nationally   with   a   focus   on   key   results  areas,  and  amongst  development  partner  recipient  countries.      

There  is  a  growing  interest  among  bilaterals   in  results-­‐based  aid  to   improve  accountability  and  return  on  aid  investment.    Donors  want  to  see  results,  health  outcomes  for  the  money  they  put  in.  Most  want  to  see  that  the  system  will  be  able  to  deliver  before  they  put  in  more  money.  The  ongoing  dialogue  with  the  government  is  focused  much  more  on  principles  of  accountability   and   good   governance   in   relation   to   the   desired   results;   it   provides   a  more  receptive  donor  environment  for  results  based  financing  to  garner  broader  support.    

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The  evolving  national  policy  environment  is  also  expected  to  have  an  effect  on  evolution  of  RBF   thinking.   The  word   “results”   in   the  Big  Results  Now   initiative   signals   a   call   for   faster,  demonstrable  impact  as  well  as  greater  accountability  (by  civil  service,  including  health)  to  the  Office  of   the  President.  There   is   considerable  momentum  behind   the  BRN  slogan   -­‐   so  RBF  is  likely  to  be  drawn  in  to  its  orbit  and  some  form  of  policy  "amalgam"  will  emerge.    A  possible   re-­‐orientation   of   the   way   Tanzania   uses   its   money,   from   input   to   output   based  financing  mechanisms  through  the  Health  Financing  Strategy,  but  also  –  in  the  early  days  –  through  RBF.      

The   nature   of   the   RBF   policy/programme   is   also   likely   to   CHANGE   -­‐   as   the   range   of  interested  actors  broadens.  

 

Study  Limitations  

Available   time   and   resource   constraints   limited   the   number   of   interviews   that   could   be  done   at   the   national   level.   While   every   effort   was   made   to   get   complete   and   balanced  information   to   address   our   objectives,   the   research   team  was   not   able   to   access   all   the  targeted   key   informants   for   interviews,   in   particular   from   the   civil   society.     A   couple   of  stakeholders   appeared   not   very   willing   to   give   an   accurate   account   of   their   stand   or  perceptions.  A  few  donor  representatives  had  been  in  their  respective  posts  for  only  a  short  time  and  therefore  were  not  very  familiar  with  the  national  discourse   in  the  health  sector  and  how  this  might  have  affected  the  RBF  implementation  process.  The  study  was  only  able  to  get  a  quick  overview  of  perceptions  and  opinions  of  a  few  managers  and  health  providers  from  the  pilot  district  in  Shinyanga,  regarding  their  understanding  and  level  of  involvement  of  the  planned  RBF  pilot  in  Kishapu  district.    

   

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5.  Conclusion  and  recommendations    

To   address   longstanding   system   constraints   towards   better   health   outcomes,   the  Government   of   Tanzania   has   been   keen   to   apply   results-­‐based   financing   in   the   health  sector.  The  process  has  been  significantly  influenced  and  shaped  by  lead  funding  partners  to  the  health  sector,  weakening  national  ownership  to  the  RBF  policy,  in  particular  in  the  early  stages.  Nine  years  on,  a  pre-­‐pilot  of  the  national  RBF  scheme  is  finally  underway,  lead  by  the  Ministry  of  Health  and  Social  Welfare,  and  backed  (to  varying  levels)  by  most  health  funding  partners,   but   in   particular   the   World   Bank.   Development   partners   have   had   different  political  agenda’s  and  Tanzania  has  been  pushed  in  many  different  directions.  There  is  now  a  real  need  for  an  honest  policy  discussion  amongst  key  national  stake  holders  on  how  they  want   to   reach   Universal   Health   Coverage,   the   real   future   direction   of   Tanzania’s   health  system,  a  system  which  will  work  within  the  Tanzanian  context.  Discussions  need  to  be  open  and   inclusive   and   include   a   wider   group   of   stakeholders,   including   Ministry   of   Finance,  Prime   Ministers   Office,   Regional   and   Local   Government,   Ministry   of   Health   and   Social  Welfare,  Civil  Society  and  the  Development  Partners.    

RBF   is   very   intense   and   operationalisation   of   RBF   remains   a   challenge.   The   Pwani  experience  as  well  as  emerging  lessons  from  the  on-­‐going  Kishapu  pre-­‐pilot  suggests  several  implementation  and  design  challenges  remain  for  its  operationalization  and  that  need  to  be  considered  in  the  scaling  up  process.  There  exist  several  concerns  revolving  around  existing  design  (Incentivising  too  many  indicators  and  health  providers’  initial  reactions  to  the  use  of  the  quality  score  tool  that  might  deflate  the  actual  payments  to  the  facilities);  timely  flow  and   adequate   oversight   in   use   of   “seed”   funds   to   qualifying   facilities;   implementation  capacity;   potential   difficulties   in   maintaining   bank   accounts,   especially   by   the   smaller  facilities;   ensuring   appropriate   governance   and   accountability   structures   and   strategies;  improved   data   collection   facilities   and   verification   systems   for   timely   cycle   payments;  effectiveness  of  existing  and  planned  formal  feedback  structures  at  all  levels  of  the  system  to   better   understand   implementation   challenges;   as   well   as   financially   and   technically  sustaining  the  initiative  in  the  longer  run,  including  the  level  of  operational  support  that  will  be  required  in  the  early  implementation  phase.      

There   are   three   major   concerns   that   need   to   be   considered,   related   to   HMIS   and   data  quality,  system  issues  and  long-­‐term  sustainability.  Close  attention  needs  to  be  paid  to  the  data  verification  process  and  the  feasibility  and  sustainability  of  scaling  this  up.  We  saw  in  the  Pwani  pilot   that  P4P  posed  a   substantial   time  burden  on  health  workers  especially   in  lower   level   facilities,   especially   the   burden   of   reporting   and   verification;   and   CHAI   was  instrumental   in   providing   the   required   support   in   terms   of   feedback  meetings,  managing  performance  data,  and  doing  verification.    Can  NGOs  take  on  this  role  and  make  the  process  more  feasible?    

Across  board,  the  dominant  concern  amongst  many  of  the  interviewed  stakeholders  is  the  continuity   in   resources   that   will   be   required   for   implementing   and   sustaining   the   RBF  strategy  on  a  severely  constrained  health  system:  financial,  technical,  managerial  as  well  as  appropriate  governance  structures.    

When   implementing   the   Pwani   Pilot,   interviewed   national   stakeholders   commented   that  this   is   huge   reform   that   needs   to   be   clearly   though   through   with   and   owned   by   the  Government  with  the  required  resources  integrated  into  the  national  budget.  Further,  there  

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was   an   emerging   consensus   amongst   national   stakeholders   of   the   need   to   explore  alternative   less   pervasive   and  more   sustainable   approaches,   including   a   package   of   non-­‐financial  incentives  towards  improving  health  workers’  productivity.  The  practice  of  financial  incentives  can  be  very  distortive  and  if  not  incrementally  increased  over  time,  the  incentives  may  not  continue  to  motivate  health  workers.  The  relatively  little  money  given  by  RBF  will  go  only  ‘so  far’,  and  there  will  be  more  demand  –  how  will  RBF  deal  with  this?  

Some  other  challenges  that  need  to  borne  in  mind:  BRN  is  being  rolled  out  and  RBF  and  BRN  are   already   clashing   in   the   same   Region   and  most   likely   in   the   same   district   -­‐   is   there   a  danger  of  one  undermining  the  other?  Alignment  of   the  two  performance  based  schemes  (RBF  and  HBF)  and  potential  tension  between  the  World  Bank  and  her  basket  fund  partners  on   the   equity   platform;   and   unpredictable   Government   disbursements   and   blockages  through  the  system.  Public  Finance  Management  has  not  been  considered   in  this  report  –  but  clearly,  systems  need  to  be  in  place  to  make  sure  that  money  reaches  the  intended  level  and  is  used  wisely  for  the  planned  purpose;  otherwise  it  is  useless  to  put  more  money  into  the  system.  There  are  some  fundamental  constraints  facing  the  health  sector  that  RBF  can’t  address  –  issues  linked  to  human  resource  for  health  and  availability  of  essential  drugs  (drug  procurement  in  bulk).  

Some  general  recommendations  from  interviewed  stakeholders  towards  promoting  better  working  relationship  between  the  Government  of  Tanzania  and  her  development  partners,  include:  

• To  agree  on  a  framework  of  mutual  accountability  between  the  Government  of  Tanzania  and  her  development  partners.  

• Openness  and  accountability  –  enforcement  of  the  Code  of  Conduct  that  development  partners  sign  with  the  Government  of  Tanzania,  to  “do  no  harm”.    

• Recognize  that  development  takes  time  (and  trust  building);  linked  to  this  is  the  tenure  of  employees   that   should  be  extended  beyond   the  present   two/three  years   to  enable  them   to   understand   recipient   countries,   accumulate   information,   knowledge   and  experience  to  say  anything  relevant  in  a  country  as  large/diverse  as  Tanzania.  

Some  RBF   specific   recommendations   from   interviewed   stakeholders  on   the  way   forward,  include:  

• Undertake   public   sector   reform   of   public   financial   management   to   facilitate   quick  disbursements   of   flexible   funds   to   facilities   according   to   need,   and   build   central   level  capacity  and  leadership  to  make  this  possible.    

• Participatory   assessment   of   the   health   sector   towards   strengthening   systems   across  board  to  make  them  sustainable  and  functional,  through  strengthening  implementation  capacity   at   regional   and   district   level   with   firm   roles   and   responsibilities   to  make   an  indicator  system  work  at  the  facility  level.  

• Invest   in   and   empower   PMORALG   to   oversee   RBF   implementation   at   the   local  government  level.    

• Integration   of   RBF   in   national   Public   Finance  Management   processes   –   starting   from  

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flow  of   funds  directly   to   facilities,  a  mammoth   task,  which  needs   to  be  contextualised  more  in  the  Decentralisation  by  Devolution  approach.  

• Adopt  a  minimum  benefits  package  which   includes  many  of   the   currently   incentivized  services   and  which  will   gradually   evolve   towards   an   insurance  mechanism,   an   output  based   provider   payment  mechanism,   potentially   one  way   for   institutionalising   results  based  financing  as  part  of  the  routine  funding  of  the  sector.    

• A   focus   on   strengthening   the   routine   information   system   which   can   precondition   a  results  based  system.  

• A   close   look   at   the   roles   and   responsibilities   of   the   CHMTs   and   RHMTs   and   how   to  ensure   RBF   is   a   part   of   a   movement   towards   improved   supportive   supervision   and  quality  assurance  practices.      

• Address   supply   side   issues   and  ensure   that   the  health   system   is   ready   to   start   results  based  financing.    

• Implement   effective   vertical   and   horizontal   accountability   mechanisms   and   feedback  structures   to   facilitate   flow   of   essential   information   and   promote   participation   and  inclusiveness  among  key  health  system  stakeholders.  

• Process   monitoring   to   see   how   the   design   needs   to   be   adapted   over   time   –   the  institutional  structure,   the  data  verification  system,  adequate  supervision   from  council  and  regional  managers  and  timely  disbursement  of  funds  at  all  levels.    

• Implementation  research  for  a  better  understanding  of  the  nature  of  incentives  that  will  drive  everyone  to  do  or  not  do  the  right  thing  in  a  given  context,  that  will  promote  team  spirit  and   intersectoral  collaboration;  as  well  as  to   learn  how  (and   if)  the  RBF   initiative  adapts  to  specific  contexts  and  needs  –  the  facilitators  and  barriers,  and  its  potential  for  system   strengthening   as   well   as   improved   coverage   of   essential   health   care   towards  better  health  outcomes.  What  will  work  best  within  the  Tanzanian  context?  Some  other  research  areas  of  interests  include:  Equity  implications  of  the  star  rating  initiative?  How  does   the   RBF   approach   affect   quality   of   services?   Does   improved   quality   result   in  increased   demand   for   services?   Does   this   seems   to   happen   across   the   board   or   are  some   services   more   affected   than   others?   Does   the   RBF   approach   result   in   better  integration   between   community   and   facility   services?     How   did   it   affect   provider  motivation?  Of  CHMTs  and  RHMTs?  Was  there  any  change   in   level  of  supervision?  Did  the  facilities  feel  more  supported?  

 

   

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