Planning, Budgeting, and Implementation Comprehensive Council Health Plans

The most important single initiative to strengthen local health service planning, budget- ing, implementation and reporting during the evaluation period has been the introduc- tion and support of the system of CCHPs prepared annually by each local council.

The annual CCHP process began in 2000 and coincided with the launching of the Local Government Reform Programme. Council planning using the CCHP was phased in, starting with 37 districts in 2000, 45 districts in 2001/2 and the remaining districts in 2003. In order to facilitate the CCHP, CHMT members received considerable training and a Procedures Manual was distributed in 2000 and revised in 2004. A third version (aligned with PlanRep2 software and including Tanzania Essential Health Initiative Project (TEHIP) planning tools) was published in 2007.

The CCHP is the principal prerequisite for any well functioning district health system.17

It includes objectives; strategies, activities to address health priorities and indicators to measure progress. The CCHP should plan for all financial resources available for health in each district.18 _{Especially in the early years, some districts mistakenly included only}

the HBF in their CCHPs, but that has been redressed. The close link between the CCHP process and the HBF is evident from the objective statements of the assessment reports on CCHP implementation; invariably, this is to “recommend them for Basked Finance Committee (BFC) approval of the release of the next quarter [basket] funds.”19

CCHP Preparation

The guidelines state that the establishment of the CCHP is the most important task the CHMT/Planning Team has to fulfil during the year20 _{and stipulate that the CCHPs}

have to include the plans and activities of all health providers regardless of the owner- ship.21

Actual planning techniques vary from district to district, but a fairly common procedure is that Heads of HFs and members of Health Committees identify health problems and send a list of these to the CHMT. The planning team analyses the health problems by cost centre, then ranks them in order of priority for inclusion in the CCHP. Beyond this exercise, the district case studies found no evidence that the CCHP benefits from a bot- tom-up consultation and planning process.

17) MOH & PORALG. 2004. Guidelines for the Preparation of Comprehensive Council Health Plans. 12th March 2004. Page 30.

18) Block, Basket and Council Grants; CHF, NHIF, cost-sharing and contributions from the community, development partners, NGOs, CSOs, etc.

19) See, for example, Report on Assessment of 4th _{Quarter Progress Reports for October-December 2002 for}

82 Phase I and II of Local Government Reform Councils, and Re-assessment Financial Quarterly Report for 121 Councils Implementing CCHPs (July-September 2006).

20) MOH & PORALG. 2004. Guidelines for the Preparation of Comprehensive Council Health Plans. 12th March 2004. Page 45.

The process of preparing the annual CCHP also appears to require significantly more time from more people than foreseen. In the six districts covered by case studies, the average number of members on the planning teams rose from 10 to 15 over the evalua- tion period, and the length and complexity of the CCHPs grew steadily.22 _{In one of the}

six districts, members of the Planning Team estimated that each member on the team had worked an average of 30 working days to prepare just last year’s CCHP.

Content and Quality of the CCHPs

In response to the different guidelines, the contents of CCHPs have changed over time. Most of the changes and tool refinement have occurred at the level of financial details and not in the coherence of the plans or their analysis and reflection on health problems. In fact, none of the CCHPs reviewed by the evaluation contain any discussion of previ- ous efforts to address health problems or options for the future.

Although the overall health priorities presented in the CCHPs are in accordance with MDGs, MKUKUTA, burden of disease and the National Health Policy, the targets are not consistently linked to the stated priorities and the use of data is inconsistent. Interes- tingly, while staff shortages, poor infrastructure, and problems with drug supplies clearly constrain council health services, they are seldom mentioned in CCHPs reviewed during the evaluation. As a result, plans are more disease-focused than system-focused.

Given that the CCHP has not yet become a dynamic planning tool, but remains mainly a rather costly budgeting tool, it is possible that a simpler and less ambitious planning process could achieve the same outcomes.

CCHP Quarterly Reporting

All CCHPs and quarterly reports are assessed and scored by the RHMTs and forwarded to the central level. A team of staff from MOHSW/PMO-RALG then compiles a report for the BFC23_{. This process is strongly focused on procedural compliance, financial mat-}

ters and issues relating to eligibility for Basket Funds. Comments on the substance and the planning process itself are very rare.

Implementing CCHP Activities

According to Nyaywa and Petersen (2007) two thirds of councils did not provide data in the CCHP on the implementation level reached for activities planned in the previous year. The district case studies generally found that CCHPs were not being used to track progress against either activity or outcome targets.

Supervision

The word supervision does not occur in the POW, but in the HSSP2 “supportive supervi- sion regularly provided to all health facilities” is mentioned as an indicator of quality im- provement. The district case studies indicate that the general orientation of supervision has become more supportive, rather than controlling or for pure accountability purposes, which was much appreciated by health staff of the facilities visited. One achievement has been to extend supervision beyond the public system to include all FBO and private

22) The length of the Mwanza CCHPs, for example, grew from about 60 pages in the early years to an average of 175 pages over the last four years.

23) Because many RHMTs are presently not functioning fully, the MOHSW/PMO-RALG team also has to assess and score many progress reports themselves.

Health Facilities (HF). On the other hand, three of the six district case studies noted weaknesses in supervision. The district case studies note that supervision by the CHMT tends to focus on logistics, administrative and data management matters (HMIS) rather than improving clinical practice.

This is not necessarily negative in the light of core tasks of the CHMT, as an arm of the Council. But quality of care should also be regularly supervised. Whether staff adhere to diag- nostic and treatment standards and protocols is, however, better supervised by more clinically oriented hospital teams, possibly contracted by the Council, than by the CHMT.