Detailed Recommendations Planning and policy development

1. Implementation of the draft HRH strategy should be started as soon as possible. (1, 2 and 3)

2. The capacity of the MOHSW and councils to forecast future demand and thus training needs, plan and manage the workforce (including FBO and private sector) needs to be strengthened. (2)

3. This could enable a decision, at some point in the future, to devolve the whole personal emolument budget to the councils. (3)

4. A review of the HRH information system should be undertaken with a view, in particular, to making more effective use of existing data by better linking currently separated data bases so that aggregate information can be made more

comprehensive and reliable. (1)

5. Facility staffing standards should be revised in consultation with relevant bodies and facility staff to reflect changing needs and demand for services, but should also reflect potential higher efficiency through better management (see below). (1) 6. Within councils, actual staffing needs should be related to utilisation of facilities,

rather than as standard allocations for all facilities at the same level. Councils should be encouraged to establish staffing levels per health facility, based on an analysis of workload and the availability of staff. (2)

7. MOHSW and representatives of FBOs and private service providers should nominate members to a task force to review pay and benefits for health workers in the system as a whole. They should identify practical measures to be taken by all three parties to reduce intra-health-system competition for staff and establish reasonable standards for pay. (1)

8. The MOHSW should investigate the magnitude of staff losses to foreign postings and identify measures that would be required to retain highly qualified staff in Tanzania. (1)

Training and development

9. Each council/CHMT should undertake a simple training needs assessment and make a general council-wide training plan. (1 and 2)

10. MOHSW and PMO-RALG should consider transferring a larger portion of the training budget to the councils, so that they can organise local workshops, seminars pay for refresher courses from the ZTC. The budget can also be used to contribute to costs of upgrading training of staff, as well as to pay for attendance at national level workshops. In that way each council can decide on their own training priorities. (3)

11. Current plans and programmes to upgrade the capacity of ZTCs should be accelerated based on verified improvements in performance. (1 and 2)

12. Regular supervision of clinical skills by the RHMT (which is problematic) should be replaced or augmented through provision of annual refresher courses organized by the ZTCs for different levels of staff. The content of these modules could be based on training needs assessments and new technical guidelines being issued. (2 and 3)

13. Health personnel professional bodies should be strengthened so that they can undertake their function of quality control of training institutes and courses. (2)

Recruitment and Deployment

14. Councils should be further capacitated to recruit professional staff and should regain the power to hire as soon as possible (in combination with power to decide on incentives to actually attract and retain qualified staff). (2)

15. Recruitment of trained health professionals to meet health personnel demands of the health system needs to be further accelerated. (1 and 2)

16. MOHSW should investigate the size of the pool of trained health workers, who have left the service, and under which conditions they would be willing to return with a view to actively recruit from this group and organize refresher courses where required. (1)

17. Large disease-specific programmes, in particular those dealing with HIV/AIDS, should assess the impact of their staffing requirements on other key areas such as maternal and child health and develop staff training and assignment support programmes which help offset any negative impacts. (2 and 3)

Retention and Remuneration

18. Incentive packages to attract and retain health personnel in rural and underserved areas should be developed and implemented on an urgent basis. Preferably on the basis of a rapid appraisal among staff and examples of what has worked in other countries. Remote and hardship areas should be financially supported to enable them to finance the necessary incentive package. (1 and 2)

19. The Directorate of Personnel and Administration and the Directorate of HRH should strengthen coordination to accelerate recruitment and salary payment for new recruits. (1)

20. MOHSW should urgently seek, and MOF, should allow an arrangement similar to the one granted to the Ministry of Education to allow newly recruited health personnel on postings to receive full pay during their probationary period. 21. Failing the above, councils could advance initial salary of new staff, in order to

bridge the period until payment arrives from the centre. (1)

22. The grading and thus salary of staff should be adjusted to recognize upgrading and/or postgraduate training. (2)

Managing the Workforce

23. Staff should have clear job descriptions, including evaluable tasks and targets so that the Open Appraisal System (OPRAS) can operate effectively. (2)

24. Promotions and opportunities for career advancement should be awarded on the basis of merit and actual performance. (1)

25. A policy to increase the efficient use of time of staff already present should be developed in conjunction with the redefinition of standard staffing establishments. This could therefore decrease the need for training new staff, leaving more funds available to upgrade existing staff’s knowledge and skills. (2)

Conclusions: Health Care Financing

1. Public expenditures in the health sector increased substantially during the evaluation period with both domestic and external sources of funds contributing to the rise measured both as per-capita spending and as a share of national public spending. GoT budget allocations to the sector and DP contributions to the HBF both added to this rise. The increase was not as sustained in most recent years and still falls short of national and international targets.

2. The allocation of on-budget resources over the evaluation period has been characterized by a gradual but steady decrease in the share allocated directly to LGAs, although their overall spending has risen significantly. Because the financial data available did not allow the evaluation to identify the proportion of MOHSW (and national vertical programme) expenditures occurring at the local level, it is difficult to determine the trend in health expenditures at local level as a share of total spending. Nonetheless, it would be useful to establish a target for the share of on-budget resources to be allocated to LGA level. 3. Despite some problems, the evaluation period has been characterized by improvements

in the budget performance in the health sector. On-budget resources (both domestic and foreign) have been more predictable and achieved higher levels of budget execution than off-budget funds.

4. Cost-sharing mechanisms implemented during the evaluation have had limited success in achieving their stated goals of raising additional resources for health, improving the quality of services and improving the operation of the referral system. On the other hand, there is some evidence they have strengthened ownership and involvement by local communities.

Issues Focus: This chapter focuses on efforts during the evaluation period to improve the level, appropriateness and sustainability of health care financing in Tanzania. It provides an analysis of the sources of funding, the levels of financing achieved and their composi- tion, the pattern of spending in health by organizational level and functional use, budget performance, and the appropriateness of efforts to introduce cost-sharing and risk pool- ing mechanisms.