Detailed Recommendations Infrastructure and Equipment

1. MOHSW in collaboration with other relevant ministries should, as a matter of urgency, find and implement methods to ensure more reliable electricity and water supply in all health facilities. Solar panels and water storage tanks can be installed where there is no grid or public water system. (2 and 3)

2. New public health facilities should not be constructed before necessary staff, equipment, drugs and supplies to provide the basic package of care in all already existing facilities are present. Only when budgeted funding ensures that new facilities can be equipped and staffed, should they be constructed, in underserved areas as a priority.

3. Health facility budgets should include an amount for (preventive) maintenance, so that maintenance contracts can be signed by HFs. Preventive maintenance costs should also be reflected in CCHPs. (2)

4. Regular inventories of medical and office equipment should be conducted in order to forecast demand and to allow for the time needed to procure these items. (1) Health Management Information Systems (HMIS)

5. The MOHSW should encourage the University of Dar es Salaam to implement planned MSc course in Health Information as soon as possible in order to improve the supply of higher trained information managers to the system. (1)

6. The HMIS Unit in the MOHSW should be strengthened with more highly qualified staff. (1 and 2)

7. A staffing plan should be developed so that CHMTs would include a full time information officer, specifically trained in data management and analysis. (2 and 3)

8. In the mean time short refresher course in health information should be developed and offered to all present HMIS focal persons in regions and councils, focusing on skills in data collection, checking data correctness, analysis, feedback and utilisation of information. (2)

9. The CHMT should organise regular meetings for officers in charge of health facilities to discuss and compare HMIS data, thereby increasing their under- standing and motivation to properly collect data and use information at facility level. (2)

10. Urgent discussions with all stakeholders are needed to reach a consensus on which indicators should and can be routinely collected through the HMIS and which are better collected through the Sentinel Surveillance system. (1)

Drugs and supplies

11. MOHSW should urgently proceed with its stated intention to allow health facilities to receive one third of their MSD allocation in cash, so that they can buy drugs and supplies in the market, and thereby introduce an element of competition to the process of drugs procurement and supply. Accompanying measures for ensuring procurement of quality drugs would be required. (1 and 2)

12. If the actions recommended immediately above produce positive results, MOHSW could increase the portion of the drugs allocation provided to councils as cash over time. (3)

13. MOHSW should assess the feasibility of linking drug allocations for primary health facilities (either in cash or as allocation with MSD) to actual utilisation, rather than all dispensaries and HCs receiving the same amount. (2)

14. Orders sent to MSD by PHFs should be rationalized so that approximately one third of PHFs send in orders in any four month period. (1)

15. The MSD should accelerate phasing in of ILS and decentralise full handling of orders to zonal stores. (2)

16. MSD should organise a training-of-trainers course for regional and council Pharmacists or Pharmaceutical Technicians/Assistants to train health facility staff in how to forecast and calculate their drugs and supplies orders. (2)

17. More attention should be given to ensuring quality standards of storage facilities for drugs in primary health facilities. (1)

Transport

18. Councils should develop a clear policy on ambulance use for transport of patients. Ambulances should not be used for administrative or representative purposes. Ambulance use in case of emergency could be included in the CHF package. (1) 19. In order to make outreach activities and home-based care a regular feature of

primary health care, staff should be provided proper means of transport, such as motorcycles. (2 and 3)

Information Technology and Communication

20. Regional Secretariats and councils should accelerate investment in information technology. RHMT, CHMT and all hospitals should, over time, make better use of Internet and e-mail facilities, and make arrangements for reliable technical back-up, support and maintenance. (2)

21. In order to facilitate urgent patient-related and necessary administrative

communication, such as calling the ambulance, councils should provide primary health facility staff with a mobile phone and a modest monthly allowance for professional use. (2)

22. For areas where there is no mobile network coverage (yet) radio communication should be installed. (2)

Monitoring and evaluation

23. In the HSSP3, in the operational regional plans and CCHPs, as well as in annual hospital plans, targets should be quantified and time-specific, with explanations for variances required in progress reports. (1)

24. GHIs and large bilateral programmes should plan their evaluations to be integrated into the evaluation schedule for the sector as a whole, as articulated by the GoT and development partners. (2)

Conclusions: Human Resources for Health

1. By all estimates, Tanzania has faced a severe shortage of skilled health sector workers throughout the evaluation period and continues to do so, although this only became a priority policy and programme focus later in the period.

2. Staffing levels are not related to actual workload at facilities level and the productivity of staff could be much higher, resulting in increased efficiency of service provision.

3. Government and private training institutions have increased their output in recent years and there have been improvements in in-service training for public health workers, most recently through strengthening Zonal Training Centres (ZTC), resulting in higher qualified staff being available in health facilities, improving quality of care.

4. Efforts to recruit, deploy and retain public health workers, especially those assigned to remote or hardship areas councils, continue to be hampered by administrative problems, the absence of an effective incentive scheme, and by loss of professional staff to other jurisdictions, resulting in lack of quality care in large parts of the country, inequities and eventually in avoidable mortality and morbidity.

5. Recent improvements in pay and benefits for public health workers have had significantly negative effects for FBO and private service providers.

Issues Focus: This chapter examines the issue of how effectively the health sector has dealt with important issues in HRH during the evaluation period. It deals with the fol- lowing elements in the sectors response to the situation:

• National goal setting in HRH;

• Planning and policy development (including assessing staff shortages); • Staff training and development;

• Recruitment and deployment; • Remuneration and retention; • Managing the workforce.