Progress in Public Private Partnership

Tanzania has had a mixed system of health services for decades. FBOs have operated hos- pitals, health centres and dispensaries literally as long as there has been a functioning health system. During the evaluation period they have been supported by the GoT through the provision of grants both on a per-bed basis and for the cost of some staff. Some NGOs have also provided community health services. The Government’s relation- ship with private (for-profit) service providers has been a different matter, as private pro- vision of health services was outlawed from 1977 until 1991 and has, in the view of many key informants, been tolerated rather than encouraged ever since.

Both the POW and HSSP2 identified strategies to promote private public partnerships. The POW in 1999 laid out the vision that the “public private mix will be promoted in the delivery of health services,67_{“ and included a specific Public/Private Mix Strategy to}

develop new ways of promoting private sector participation, contracting out services and adopting the required legislation. In short, according to the POW, the government “adopted a policy of complementation rather than confrontation with the private sec- tor,68_{“ and the Government was “to be more of a facilitator than the main provider of}

health services.69_“

Four years after the POW was published, the HSSP2 noted that “the only significant achievement reported [within the area of PPP] is the registration of new facilities.70_“

67) POW, p.1. 68) POW, p.6. 69) POW, p.12. 70) HSSP2, p.12.

Furthermore, HSSP2 stated that there was generally poor collaboration between the pri- vate sector and government, and that an atmosphere of mistrust between the public and the private sector continued to prevail. HSSP2 indicated that the way forward was to support the formation of networks for interaction between the private and public sectors. In 2005 the MKUKUTA repeated the political commitment to PPP. It called for “forg- ing partnership with all other stakeholders, including CSOs, private sector, and FBOs, in the provision of quality social services.71_”

Recurring reference to PPP in all JAHSR reports is indicative of the importance attached to PPP and the distance still to be covered in this area. The following table highlights what the reports from the JAHSR have noted on PPP.

Table 5: Highlights on PPP from reports of the JAHSR

Year Extracts from JAHSR reports

2000 PPP was a priority issue for discussion.

2002 It was resolved that private sector representatives were to become part of the CHMTs. 2003 FBOs were complaining that they were not integrated into the health planning process

at district level, and that they were losing large numbers of staff to the government because of the better pay and benefits offered in the public sector. It was also made clear that mutual suspicion persisted in the partnership between government and the private service providers.

2004 It was acknowledged that increases had been made in the bed-grant subvention and that a draft “service agreement” for contracting with non-government providers had been drawn up.

2005 The need was emphasised to replace the current government subsidy (i.e. grant subventions) to FBO-providers by a service agreement linked to outputs. Another resonating theme was the need to expand the opportunity for non-state actors to participate in health planning and management at district level.

2006 Many participants voiced dissatisfaction with the lack of progress during the year. Service agreements were still not implemented, and staff continued to emigrate from non-profit to government employment because of the recent salary improvements in the latter.

Source: Reports from the JAHSRs.

As the highlights from the JAHSR reports show, some critical aspects of PPP have not progressed much over the evaluation period and the same issues appear to be on the agenda year after year.

In 2005, the independent Technical Review focused specifically on the promotion of PPP.72 _{As these reviews are meant to feed into the JAHSR, this, in itself, was a manifes-}

tation of the importance attached to the issue by the major stakeholders. The review

71) MKUKUTA, p.49.

72) HERA. 2005. Technical Review 2005: Public Private Partnership for Equitable Provision of Quality Health Services.

described the variety of non-state actors in the health sector. It pointed out that roughly 40% of health services in Tanzania (more in urban areas) are delivered by non-state pro- viders. Furthermore, it stated that FBOs made a large contribution and some of the FBO hospitals had been assigned district responsibilities (so-called District Designated Hospi- tals). The not-for-profit services by FBOs were complemented by a range of activities by NGOs, often with external funding and increasingly HIV/AIDS related. The private (for profit) side had even greater variety, with a range of private hospitals, pharmacies, labora- tories, maternity homes etc.73

The Technical Review presented the key elements of PPP in Tanzania’s health sector. It stated that the Government provided funds for recurrent expenditure of 21 FBO hospi- tals (19 DDH and 2 Consultant Hospitals) and bed and staff grants to 62 FBO owned hospitals. However, it also pointed out that the Medical (grants-in-aid to voluntary agen- cies) Regulations started as early as 1952 and the practice of using DDH agreements began in 1972. According to one centrally placed observer, “these are the only means that have so far been used to foster the public private partnership in the country.74_{“ While}

this statement may reflect the principal government effort to promote PPP, it should be added that the Government also provides student grants for training schools run by FBO hospitals, and that Voluntary Agency Hospitals in the districts are entitled to receive 10%-15% of the HBF and Block Grants.

Apart from the above, NGOs and CBOs make important contributions to the health sector and they may be regarded in the context of PPP. Community-based health promo- tion and prevention services, which are mostly done by NGOs and CBOs, are not as well documented as mainstream health service delivery since this is not routinely captured by the HMIS and more often reported in project reports. Partly due to their large numbers and diversity, juridical arrangements, objectives, etc., health NGOs have not been suffi- ciently well organised. As a result, the NGO sector is somewhat excluded from policy discussions and strategic planning, especially at central level. At the local level, collabora- tion with CHMTs seems to be more effective, but varies from district to district depend- ing on pro-active attitudes of NGOs and CHMTs.

The Technical Review produced a list of about 20 specific recommendations to promote PPP. To date, almost none of these have been implemented. However, the evaluation noted that in all of the six case study districts public funds were allocated to Voluntary Agency Hospitals (FBO operated). Furthermore, it was ascertained that in each of the six districts the CHMTs engage in supervision of FBO and private health facilities. These findings corroborate some of the changes highlighted by the District Self -Assessment (Synthesis Report, April 2007, p. 25).

In contrast with the district self-assessment (p. 25), the evaluation did not find that: “there is recognisable public private partnership mainly in the areas of planning and training.” First, the individual reports from the 16 districts covered by the District Self Assessment show a more nuanced picture. While several of the individual reports men- tion that there has been participation in planning, they also contain many qualifiers in this respect. For example, the extent of participation has in many districts been restricted

73) The Association of Private Health Facilities in Tanzania (APHFTA) currently has around 250 members.

(to e.g. one large FBO), there has been poor attendance, or it has not gone beyond co- ordination, inputs or information sharing.

Reviewing a number of CCHPs, the lists of members on the council planning teams indicate that some FBO participation was generally the rule. But, based on the interviews done, the district case studies found that real FBO and private sector participation in the preparation of CCHPs was very limited in the six districts visited. Simply having a mem- ber on the planning team is no guarantee of participation or influence. While some FBO participants (in Same and Njombe for example) did indicate that they participated meaningfully in the CCHP process, others noted that their participation was minimal. Private service providers on the other hand, were largely unaware of the CCHP.

Training and seminars may be one of the areas where there have been some improve- ments in PPP. Again, several of the district self-assessments reports refer to achievements in this area. But the limitations are also pointed out: unequal access to training (in some cases) by public and non-public health professionals. Training and seminar activities are not planned in response to the needs of both of these targets groups. On the other hand, in most cases non-public health professionals may be invited to participate in training events designed for public sector staff.

The district self-assessment reports highlight joint vaccination and community sensitisa- tion programmes and preventive services as areas of PPP achievement. While this is an area of PPP that has undoubtedly contributed to increase coverage and accessibility to essential health services, the process is designed with a bias in favour of the public sector. Many non-state actors appreciated the opportunity to take part in such campaigns, but the evaluation also heard complaints that they were obliged to participate in e.g. nation- wide vaccination campaigns without being compensated for staff time or the use of their facilities. In such cases, private HFs only receive the drugs and supplies required to implement the activities.

In a few of the six districts visited, both public and non-state actors mentioned that they benefited from a technical dialogue with colleagues “on the other side.” Key informants also noted that some FBOs and private sector providers have been certified to provide health services to public servants who are covered under the NHIF.

Some of the individual district self-assessment reports make reference to a practice of exchanging professionals and secondment from public health providers to private health providers and vice versa, which is reported to have strengthened the collaboration between the public and private sectors. The report for Mkuranga District Council, for example, states that staff from the public hospital is sent to work in a private clinic in order to improve the quality of health service. This practice was also observed in the dis- trict case study of Kigoma Municipal Council.

It is also worth pointing out that councils do provide financial support to FBO hospitals working in their district and the district case studies regularly found a reasonably high level of cooperation between the CHMT and at least the larger FBO hospitals.

The evaluation found only a few PPP co-ordination mechanisms in the six districts, despite the fact that these had been singled out in the POW and HSSP2 as holding par- ticular promise. A Lake Zone PPP Forum has been established (with DP support) and two years ago council quarterly meetings had been institutionalised in Mwanza in order

to bring together all the actors in the health sector, public and private. Both of these were reported to have increased transparency and the degree of information sharing.