DSMPHDS organisation capacity: problem analysis

In the mid-1990s, an assessment was carried out on the DSMPHDS administrative, management and organisational capacity. Since then, many activities have been implemented to contribute to the goals set out in the first version of the MPHMA. The DSMPHDS has changed significantly over the 1990s and its' administrative, management and organisational capacity has improved significantly. However, the original assessment is still relevant today as it was then, and should be referred to given that changing administrative, management and organisational attitudes and practices is a long-term objective of the DSMPHDS. Later, in Chapters 6 and 7, the DSMPHDS current administrative, management and organisational status is presented in detail.

The situation analysis of the DSMPHDS structural and functional capacities carried out in 1994 became the core of the DUHP Phase II implementation strategy and set the basis for the implementation of the health sector and local government reform proposals. Indeed, it was found that the DSMPHDS did not have the organisational, managerial and administrative pre-requisites to implement the HSR proposals, nor to improve the quantity and quality of services. In 1994, DUHP/DSMPHDS started to implement its core strategy - "From management of disease to management of health system" - that focussed on the setting of sound integrated organisational, managerial, administrative and clinical sub- systems. One has to note that the shortcomings identified in the DSMPHDS organisation are not those that can be reformed in a short period. They are part of the problems identified by the HSR and are still nowadays largely present.

• Decentralisation without true devolution

Since the end of the colonial period, there have been several shifts in the stance of the Government of Tanzania towards decentralisation, which has created considerable confusion among the population and government authorities. As a result, although decentralisation is now formally proceeding, authorities at all levels of the government system are still not truly implementing their “new” responsibilities based on their newly acquired authority. It seems that the rules of the game are not clear: confusion still exists over the roles, functions and mandates of political and administrative authorities, as well as between the authority and responsibility of the national. regional, districts and health facility levels. Finally, a general contradiction may be seen between the decentralisation processes of Government of Tanzania (RLG, Civil Services, Health Sector Reforms, etc.) and the introduction in 2000/1 of the Rlocal Government reforms and of the sector-wide approach.

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Indeed, one can see that these reforms represent a horizontal re-centralisation of the DSMPHDS health sector to the municipal authorities and a vertical re-centralisation to the Ministry of Health.

This confusion and overlapping roles and responsibilities of the various governmental and political authorities, added to traditional authoritarian behaviour, makes it tremendously difficult to implement true decentralisation in the health system. Added to this, within the health system one also has to take into account the authority of medical staff over administrative and other clinical staff.

• Informal decision-making processes, the technical "know whom"

In every organisation, the structure of authority has to consider the “political” impacts of its administrative decisions and the pressure of its socio-cultural environment. A necessary equilibrium has to be found through continuous negotiations between the various authorities that influence decisions.

As far as the DSMPHDS is concerned, the equilibrium has yet to be found. Indeed, the weight of the political and socio-cultural environment is prominent. Interference from the environment in decision-making processes occurs regularly. This situation prevails not only in important matters, but also in day to day activities. The weight of this informal decision making process puts the system in contradiction, and threatens the credibility of the whole decentralisation process. A good example of this behaviour and concentration of authority that still persists today is the nomination procedure of various cadres in the system. One of the main reforms yet to implement in is the open selection processes of senior cadres.

• Weakness in the planning process

Planning in an organisation has to be seen as a process that goes from identifying priorities and elaborating plans, to monitoring and supervising implementation, and to evaluating results. It is a cyclical system in which inputs, throughputs (managerial and administrative processes), outputs and feedback form a loop that is self-regulating. In order to ensure efficiency and effectiveness, all sub-systems (organisation, resources, programmes, and environment) have to be linked together. It also has to be comprehensive (including all resources and objectives) and at the same time realistic, which means that it has to be based on a sound knowledge of its “minimum” implementation capacity. Importantly, to be successfully implemented it has to be elaborated from a bottom up perspective in which all

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operational partners at implementation levels are involved. Finally, the operational process has to be closely monitored, supervised and evaluated.

The DSMPHDS started implementing such a process in 1996. Six years later, the impacts of the Rlocal Government reforms and MoH SWAp should be evaluated. In brief, from the point-of-view of the DSMPHDS, the health facilities were barely involved in planning, and when they were, it was usually to inform them about the MoH planning methodology, objectives and funding (SWAp). Also, supervision activities are hardly carried out. Indeed, it seems that the municipal (RLG) authorities are managing on an ad hoc basis, that jeopardises the implementation of the planned and scheduled activities of the health system. It is also apparent that there is little decentralisation of the funds to implement the plans of operation. Such a situation creates undue delays and often prevents the facilities from implementing planned activities.

• Weakness of liaison and co-ordination mechanisms, lack of standardisation of

managerial and technical practices

As any health organisation, the DSMPHDS can be regarded as a professional bureaucracy. Professional because of the complexity of its’ programmes that necessitate highly skilled and trained staff at all levels and sophisticated instruments. Bureaucratic because of the necessity of having well trained staff with predetermined standardised qualifications that are applied through predetermined programmes. This kind of organisation definitely needs to function through standardised managerial and administrative policies and procedures.

Weakness of liaison and co-ordination mechanisms. The DSMPHDS had a managerial approach based on conformity to social and administrative norms rather than on the implementation of planned objectives and activities. This approach is still prevailing (2002) in its relation to the immediate environment: the Local Government, Ministry of Health and other authorities. This deeply rooted behaviour is a major impediment to the functioning of a “modern” health system, based on the autonomy of its professionals, and to the implementation of the Health Sector Reform proposals. Indeed, both are based on a subsidiary approach where decentralised facilities and services are supposed to take decisions at their level of implementation. The system is still mainly based on an approach where norms and the fear of authority render difficult the development of individual initiatives. We also argue that the health system environment is still not so conducive and appears reluctant to really give the authority that would match the currently decentralised

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responsibilities: from MoH to DSMPHDS and from DSM Municipalities to MMO Hs and from MMOHs to health facilities.

The DSMPHDS was poorly co-ordinated. The system had already district health management teams along with regional management teams. However, in general and probably due to the reasons identified above, they looked more like a place where information is given by the authorities and vice versa for day to day operations, rather than a two-way flow of information and open discussion where organisational, functional and operational problems can be resolved. In particular, we may say that the system did not have the necessary planning methodology nor the functional organisation to do so. Moreover, it seems nowadays that the co-ordination structure put in the DSMPHDS formal charts at all levels and units are hardly functioning. Indeed, the various health management teams at the MMOH and health facility level are not holding their planned regular and formal meetings.

Low standardisation of management and technical practices. The DSMPHS in the past has virtually been working in a vacuum of policies, norms and procedures. Indeed, we may say that even the outdated general GoT, MoH, various professional acts, and administrative procedures were not known, and if so, they were ignored. Here we speak about the core standardisation of the health system objectives, activities and related organisational, administrative and technical policies and procedures. What were the basic services that the system had to deliver and with what basic human, material, financial, and information resources? What were the basic standard treatments to implement in connection with the basic health programmes? Once this Minimum Package of Health and related Management Activities (MPHMA) was known, it became possible to elaborate and implement standardised organisation and functioning processes. And, finally, it became possible to rationalise the resources and elaborate an “implementable” plan of operations.

• Weaknesses in integration of activities, confusion in function separation and in task

description and dysfunctional referral system

As said previously, the DSMPHDS is a multisector system, situated in the socio-cultural, socio-economical and socio-political complex environment of a large city in a developing country. We are speaking of close to one hundred institutions in the public health system and of well over one thousand employees; of vertical programmes mainly administered by the Ministry of Health; of the planning policy and funds related to the sector-wide approach; of a system where bilateral and multilateral organisations are still intervening in various parts

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of the system; and of a system where the private “modern” and traditional health sectors are not heavily monitored and restricted in their activities. Therefore, who knows exactly what

is happening? Who is qualified to co-ordinate and supervise? The MMOHs through

their “Private Health Facility Secretariat" are making some progress. However, the general supervisory capacity of the DSMPHDS is yet to be organised. Indeed, since the decentralisation to the municipal level, the city/regional health authority is yet to receive the means to achieve its' co-ordination mandates.

The mission, functions, role and tasks were not updated and distributed functionally between its various tiers, services and staff. Confusion existed between implementation and supervision or regulatory capacities of the various units. Missions, roles, functions and tasks were overlapping. Several people were responsible for activities aiming at the same goal. No one really had a clear vision and understanding of its missions, functions, role and tasks. The system itself in general, and the senior managers and staff in particular, were facing a great need for a precise identification of each tier’s mission, functions, roles and tasks. A great deal of work was done in that sense since the implementation of the first version of the MPHMA. However, considering the high staff turnover of the system and the number of newcomers at the RLG (municipal level), a new systematic sensitisation should be done. Indeed, the human resources “orientation” policy has not yet been implemented, and, slowly but surely, the DSMPHDS is loosing its' institutional memory.

• Low capacity and credibility of administrative activities

Absence of an administrative services division (1995). The administration of human, material, financial, information and time resources was not integrated into structural units, and some, like information and time management, simply did not exist. This absence of co- ordinated administrative units may be seen as part of the (then) general health sector and the philosophy of management of the Government of Tanzania.

Indeed, this centralised system was not based on devolution, and all the decisions related to funds were not taken at an operational/implementation level, but rather at a “political” level. The in-charges (I/c) of the facilities and of other services were generally medical doctors that gave limited responsibilities to the junior administrative staffs. In such a system, the I/c had a wide span of control in which each administrative staff member (administrator, procurement officers, accountants, secretaries, drivers, cleaners, etc.) was directly answering to him. In the best cases the I/c was working hand in hand with the “Health Administrator”. However, the health administrators’ core training was based on the administration of human resources,

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and subsequently very few were knowledgeable or interested in administering material and financial resources. Also, the in-charges of facilities were not qualified in resource administration. The administrative staff, being isolated, were not in a position to create a synergy that could improve their outputs. Administrative activities were then carried out on an ad hoc basis by staff with few qualifications.

The system had no maintenance policy, norms and procedures; inventory was rarely taken and generally not updated and procurement was done on an ad hoc basis following more the political norms of the environment rather than the financial regulations of the government. The system was not practising any time management and the health information system was obsolete. Secretarial activities were underestimated and the filing systems did not exist. In brief, the system was not well administered, and the scarce resources were generally dilapidated.

Absence of true commitment to human resources management, few qualified staff and lack of staff allegiance to the organisation. DSMPHDS is a relatively young organisation. A lot of its' senior staff have been trained in different countries and from different agencies with their own ways of doing things. Other staff received a training from Tanzanian institutions and are continuously trained and updated by a multitude of different trainers on a multitude of different topics. No follow up is given after training. Staff generally do not read documents provided to them and have little motivation for their jobs. Finally, a high turnover rate makes it difficult, if not impossible, to maintain some kind of trademark and to build an institutional memory in the DSMPHDS.

It is not a secret that the DSMPHDS staff have been unmotivated and unproductive, have low qualification in public health, health management and health administration. The DSMPHDS cannot by itself replace the low performance of the educational Tanzanian system. A health system should be in a position to hire pre-qualified staff with standard qualifications. It cannot continuously retrain its’ staff. However, considering the cadre’s management capacity, it puts a lot of resources into increasing their management and administrative knowledge. This being said, training should be supported by changes in the organisation, otherwise the trained staff are back at square one.

The common excuse to explain the poor staff commitment and performance is always related to their low salaries, which makes understandable some of the reports of poor performance: absenteeism, “per diemitis”, prevarication, bribery, bad manners, roughness

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with the patient, absence of allegiance to the organisation, etc. Furthermore, no salary premium is paid for managerial or administrative responsibilities. The DSMPHDS cannot by itself resolve these problems and change the staff attitude. However, it tried through the elaboration of a manpower plan and through some incentive policies based on performance to reduce the phenomenon.

Moreover, management of staff proceeded from the juridical administrative approach described above. Indeed, the system was not truly implementing a human resources management policy but rather a timorous personnel administration of salaries and fringe benefits. All other matters related to staff well being and career development were/are not truly dealt with or they were dealt with through informal management: the classical "know whom". It is also true that, the DSMPHDS did not have any real authority over its' staff who are answerable to the civil service department, and not to the Ministry of Health.

Implementation of true Administrative Services Units. The administration of the DSMPHDS resources has been facilitated and improved by the implementation (in 1999) of an administrative services department at the MMOH and municipal hospital levels (see chapter 6). These services are sub-divided into human, material and financial resources units. At the health centre level, while the administrative service division appears in the chart, they are yet to be staffed with fully-qualified administrators, accountants and clerks. Administering human resources in the Tanzanian public health sector is not an easy task. Indeed, on the one hand, it is still the” technical know whom” which dominates the “technical know how”. On the other hand, an obsolete formal juridical staff administration still prevents the development of a human resource administration approach. Staff are still nominated and not selected. The facilities still face a high turnover rate. Staff generally have low technical qualifications. Their outdated salary partly explains their attitudes and practices such as their absenteeism, “perdiemite”, corruption and rude attitude toward patients. Staff are generally not motivated and the health system administration can do little for it beside an ad hoc distribution of equipment and training/seminar per diems.

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• General improvement of quality of care and of the participation of the population

Previously, the DSMPHDS did not have any community based health care (CBHC) or Information-Education-Communication (IEC) strategies. Neither did it have (before 1995) any formal or informal place in its organisation for the population involvement in its' own health. A study in October 1992 on the quality of primary curative care in Dar es Salaam identified that, as far as structural, technical and interpersonal quality of care are concerned, DSMPHDS quality of care is generally poor (Kanji, Kilima et al. 1992). Most facilities needed general rehabilitation and essential diagnostic equipment. They faced major problems related to the quantity, management, logistics, and leakage of drugs. The overall technical quality of services was low. The main problems in the clinical work were the failure to take an adequate history from patients and to carry out adequate examinations. This meant that the diagnoses were often incorrect. As far as prescribing practices are concerned, a study done in 1994 identified significant gaps and weaknesses in the knowledge of pharmacotherapy treatment of common illnesses such as diarrhoea and malaria (Tafesse 1995). As far as interpersonal quality is concerned, 52% of the patients judged acceptable the following criteria: making patient comfortable, allowing patient to explain the problems, explaining the diagnosis and the treatment to the patient and ending the consultation politely. Further studies on quality of care revealed that the situation has generally improved since then: facilities have been renovated and equipped, drugs procured and staff better trained. The population is formally represented through facility health boards and supported by a DSMPHDS Health Board association.

Nevertheless, a lot still has to be done concerning quality of care, as perceived by the community. Indeed the major bottleneck that the DSMPHDS is still facing is related to the staff attitude towards users of the services. History taking and physical examination are not properly and systematically done, it lacks seriousness and accuracy, and patients still have to bribe the professional to receive services.