59 research outputs found
Understanding Stakeholders’ Roles in Health Sector Reform Process in Tanzania: The Case of Decentralizing the Immunization Program.
No full textThe current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, in-depth interviews, key informants interviews and observations. Quantitative methods involved retrieval of secondary data, health facility survey and household surveys. Regular discussions with key informants and data collectors were held to verify the findings. Qualitative data was analysed manually. Quantitative data was captured and analysed using Epi Info version 6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do reforms learn from history? Analysis of the waves of health reforms prior to the current reforms from 1926 was done to answer the question. The main stakeholders in the reforms were the political party in power, the government and donors who supported the reforms each time. Each wave of health sector reforms provided information on health provision, financing and resource generation. Due to the political contexts, information on failures of health financing did not provide lessons for succeeding reforms of the health sector. Stakeholders’ political interests opposed lessons that did not match the political ideology at the time i.e. free public services versus privatization and paying for social services. Lessons from previous health reforms were selective, and did not consider health-financing needs among others. The ongoing health reforms needed to use information from all functional aspects of the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health reforms and what were their interests and reactions? The main stakeholders were donors, and the government. The two had a very high support for the reforms evidenced by their participation in problem identification, justification, reform design, planning and implementation. The health sector reforms thus had high political support at central level. In the implementation process, issues that triggered stakeholders’ reaction included sectoral versus local government decentralization. Another issue was the donor modality in financing the health sector and need for adopting new financial management systems. Among the donors there was hesitancy to join the common financing modalities that included a Sector Wide Approach (SWAp) and Basket Funding. As a result, there was delay in the process in order to reach better consensus. The third question was: What was the impact of stakeholders in the process of reforming a vertical programme like EPI? Health Sector Reforms in EPI included integration of generic functions, for example, vaccine procurement to medical stores department. Qualitative and quantitative data was collected and analysed from the Ministry of Health, EPI management unit. This again revealed that EPI reforms were well supported by the government and donors centrally. EPI managers at both district and regional levels opposed some of the EPI reforms. They argued that coverage was falling due to the reforms. However, there was no concrete evidence relating reforms in the EPI programme and falling coverage. The primary aim of certain actors was to make sure that they continued receiving extra income from EPI functions. One of the effects of stakeholders’ reaction was reversal of reforms (recentralization) and return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to decentralization at district level and how might it have affected performance of EPI functions and the challenges? The immediate reaction of stakeholders was reduced cooperation between the Council Health Management Team (CHMT) and the District Council who were politically supreme in the district. Within the Council Health Management Team there was inadequate communication, which led to poor teamwork. The result of this was reduced supervisory visits to peripheral health facilities. The EPI coverage in the study district was 52.8 per cent, which was well below the previous national average (80 per cent). A logistic regression model for EPI service quality variables on children between 12 months and 23 months who had completed vaccination was applied. Certain EPI quality of service variables predicted significant changes in the odds ratio for completing vaccination. It was then suggested that strategies were needed to improve management skills among the CHMT and District Council members. Also there was a need of hastening the process of increasing remuneration and motivation of peripheral health workers. The fifth and final question was: What was the interest of the stakeholders and prospects of increasing EPI coverage at district level? Decentralization and integration of EPI functions were among the reforms at district level. The analysis revealed that active stakeholders at district level were the Ministry of Health, CHMT, EPI managers at district and regional levels and facility providers. The Ministry of Health opposed integration of EPI at district level by issuing the directive that DCCOs and MCHCOs (EPI manager at district level) should resume their tasks. However, the CHMT had no option but to comply. This action reversed some of the health reforms at district level. Analysis of the importance the community attached to EPI, using willingness to pay for EPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI service quality variables were significantly negatively associated with odds ratio for willingness to pay for EPI input. Simulation with Policy Maker computer software predicted that an increased number of stakeholders through community participation would significantly improve the current low level of EPI coverage. It was then proposed to do a similar analysis in other vertical programmes and implement on a trial basis the results of the simulation. In conclusion, stakeholders were found to be active and influential in the health sectors of developing countries like Tanzania but poorly considered in implementation of reforms. Stakeholders are important since some strongly support while others oppose the reforms. The reaction of stakeholders is evident through deployment or non-deployment of information depending on interest and context. This would result in poor management leading to inefficiency in resource use, which would then be followed by poor quality of services, poor support by communities and consequently poor utilization of health services. It is suggested that stakeholder analysis be conducted in other vertical programmes in the process of integration. Promotion of stakeholder analysis and also Policy Maker as a tool to manage stakeholders will facilitate the management of reforms in the health sector
The Impact of Adult Deaths on unildren's Health in Northwestern Tanzania
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T'he AIDS epidemic is dramatically increasing mortality measles, oral rehydration salts, and access to health cate of adults in many Sub-Saharan African countries, with can do to nmitigatet he impact of adu]t mor tality. potentially severe consequences for surviving family These programs disproportionately improve health members. Until now, most of these impacts had not been outcomes among the poorest children and, within that quantified. group, among children affected by adult mortality. Ainsworth and Semali examine the impact of adult In Tanzania there is so much poverty and child health mortaLity in Tanzania on three measures of health amrong indicators are so low that these interventions should be chiidren under five: morbidity, height for age, and targeted as much as possible to the poorest households, weight for height. The children hit hardest by the death whlere the children bit hardest by adult mortality are of a parent or other adult are those in the poorest most likely to be found. (Conceivably, the targeting households, those with uneducated parents, and those strategy for middle-income countries with severe AIDS with the least access to health care. ep.demics, such as Thailand, or countries with less Ainsworth and Semali also show how much three poverty and better child health indicators might be important health interventions - immunization against different.)\u
Trends in immunization completion and disparities in the context of health reforms: the case study of Tanzania.
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Of global concern is the decline in under five children mortality which has reversed in some countries in sub Saharan Africa (SSA) since the early 1990 s which could be due to disparities in access to preventive services including immunization. This paper is aimed at determining the trend in disparities in completion of immunization using Tanzania Demographic and Health Surveys (DHS). DHS studies randomly selected representative households from all regions in Tanzania since 1980 s, is repeated every five years in the same enumeration areas. The last three data sets (1990, 1996 and 2004) were downloaded and analyzed using STATA 9.0. The analysis included all children of between 12-23 months who would have completed all vaccinations required at 12 months. Across the time periods 1990, 1996 to 2004/05 the percentage of children completing vaccination was similar (71.0% in 1990, 72.7% in 1996 and 72.3% in 2005). There was no disparity in completion of immunization with wealth strata in 1990 and 1996 (p > 0.05) but not 2004. In 2004/05 there was marked disparity as most poor experienced significant decline in immunization completion while the least poor had significant increase (p < 0.001). All three periods children from households whose head had low education were less likely to complete immunization (p < 0.01). Equity that existed in 1990 and more pronounced in 1996 regressed to inequity in 2005, thus though at national level immunization coverage did not change, but at sub-group there was significant disparity associated with the changing contexts and reforms. To address sub-group disparities in immunization it is recommended to adopt strategies focused at governance and health system to reach all population groups and most poor.\u
Understanding stakeholders' roles in health sector reform process in Tanzania : the case of decentralizing the immunization program; draft inaugural dissertation
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The impact of adult deaths on children's health in Northwestern Tanzania
No full textThe AIDS epidemic is dramatically increasing mortality of adults in many Sub-Saharan African countries, with potentially severe consequences for surviving family members. Until now, most of these impacts had not been quantified. The authors examine the impact of adult mortality in Tanzania on three measures of health among children under five: morbidity, height for age, and weight for height. The children hit hardest by the death of a parent or other adult are those in the poorest households, those with uneducated parents, and those with the least access to health care. The authors also show how much three important health interventions-immunization against measles, and rehydration salts, and access to health care-can do to mitigate the impact of adult mortality. These programs disproportionately improve health outcomes among the poorest children and, within that group, among children affected by adult mortality. In Tanzania there is so much poverty, and child health indicators are so low that these interventions should be targeted as much as possible to the poorest households, where the children hit hardest by adult mortality are most likely to be found. (Conceivably, the targeting strategy for middle-income countries with severe AIDS epidemics, such as Thailand, or countries with less poverty and better child health indicators might be different.)Health Monitoring&Evaluation,Early Child and Children's Health,Disease Control&Prevention,Early Childhood Development,Public Health Promotion,Adolescent Health,Early Child and Children's Health,Health Monitoring&Evaluation,Street Children,Youth and Governance
The Impact of Adult Deaths on Children's Health in Northwestern Tanzania
No full textThe AIDS epidemic is dramatically
increasing mortality of adults in many Sub-Saharan African
countries, with potentially severe consequences for
surviving family members. Until now, most of these impacts
had not been quantified. The authors examine the impact of
adult mortality in Tanzania on three measures of health
among children under five: morbidity, height for age, and
weight for height. The children hit hardest by the death of
a parent or other adult are those in the poorest households,
those with uneducated parents, and those with the least
access to health care. The authors also show how much three
important health interventions--immunization against measles,
and rehydration salts, and access to health care--can do to
mitigate the impact of adult mortality. These programs
disproportionately improve health outcomes among the poorest
children and, within that group, among children affected by
adult mortality. In Tanzania there is so much poverty, and
child health indicators are so low that these interventions
should be targeted as much as possible to the poorest
households, where the children hit hardest by adult
mortality are most likely to be found. (Conceivably, the
targeting strategy for middle-income countries with severe
AIDS epidemics, such as Thailand, or countries with less
poverty and better child health indicators might be different.
Broad roads in a thin country - infrastructure concessions in Chile
No full textTo increase investment in infrastructure, in the early 1990s Chile's government introduced private capital into the transport infrastructure sector, covering roads and highways, bridges, tunnels, and airports. The chosen mechanism: a concession scheme through which private firms would finance and build a given project and then operate the infrastructure for a set of number of years, recovering their investment by collecting tolls from users. Among the lessons learned from the experience: 1) As much as possible, avoid concessioning roads for which there are convenient alternative freeways nearby. 2) Choose the right variable for awarding a concession. Avoid mechanisms that (by promoting large payments to the state or short-term concession periods) encourage high tolls, and if you choose to award a concession to the firm charging the lowest tolls, place a floor and ceiling on possible bids. The floor is to guarantee the concession's financial viability; the ceiling is to prevent inefficient traffic diversions. Ties at either end should be resolved by a second variable, such as the level of transfers between the state and the firm. 3) Allow downward toll flexibility so that the concessionaire can react to unexpectedly low traffic flows, especially for certain types of vehicles. 4) Pay special attention to the tendering mechanism and to the general incentive structure. There are limits to the pure least-present-value-of-revenue (LPVR) auction, but income guarantees do enhance liquidity. In fact, a minimum-income guarantee through an LPVR auction is an instrument for credit enhancement, not income support. Alternatively, some form of financial innovation should be encouraged to make debt service commitments more flexible. 5) If concessions are tendered by traditional methods and income guarantees will be given, cover only a fraction of the concessionaire's expected income stream, to reduce the state's financial exposure and to improve the incentives to the concessionaire. 6) Make the contracts as complete as possible but allow for later modifications or renegotiations, and include a well-designed dispute resolution mechanism.Banks&Banking Reform,Roads&Highways,Decentralization,International Terrorism&Counterterrorism,Public Sector Economics&Finance,Public Sector Economics&Finance,Roads&Highways,Airports and Air Services,Banks&Banking Reform,Toll Roads
Food insecurity and coping strategies among people living with HIV in Dar es Salaam, Tanzania
No full textAbstract: Food insecurity and malnutrition seriously impedes efforts to control HIV/AIDS in resource poor countries. This study was carried out to assess food security, and coping strategies among people living with HIV/AIDS (PLHIV) attending Care and Treatment Centre (CTC) in Dar es Salaam, Tanzania. A structured questionnaire was used to interview randomly selected adults (≥18 years) who were HIV positive who have just been eligible for anti-retroviral treatment (ART) in a CTC or one who has started ART but not more than four weeks has elapsed. A total of 446 (females=67.9%; males = 32.1%) people living with HIV/AIDS attending CTC were interviewed. About three quarters (73.1%) of the respondents were 25-44 years old and most (43.9%) were married. Two thirds (66.7%) of the respondents had primary school education. Seventy percent reported to have a regular income and 63.7 % with a monthly income of less than US 154) (OR=0.10; 95%CI, 0.01–0.67). Reporting two or less meals increased the likelihood of food insecurity (OR=4.2; 95 % CI1.7-9.8). Low frequency of meals was significantly more prevalent (18.6%
Decentralizing EPI services and prospects for increasing coverage: the case of Tanzania.
No full textPrimary health Care (PHC) strategies were adopted widely in 1978 after the Alma Ata declaration to improve accessibility to health services and the health of the people. Of the strategies of PHC was the decentralization of health services to lower levels in order to enhance participation and responsiveness of the health system to local problems. While PHC was being promoted vertical programmes such as the expanded programme on immunization (EPI) were also being promoted and achieved substantial benefits. However, almost 25 years later many countries have not been able to achieve these health goals. This study addressed the question: Can we make the process of health care decentralization more likely to support health system and EPI goals? This study analysed the experience of EPI decentralization at national, regional and district levels. Several stakeholders were identified who were supportive and others who were non-supportive of the process. Community support to EPI measured by using willingness to pay (WTP) for kerosene (to keep vaccines cool) was low. It was significantly (p < 0.05) associated with whether providers in the nearest health facility properly attended the target population and whether the providers in the facility were available when needed. There was a substantial stakeholder support and opposition to the process of decentralization at the district level. Community support was not high possibly due to the perceived non-availability of the service providers and their lack of awareness of the population they serve. It was proposed that reforms should give priority to the involvement of communities and peripheral health facility providers in the process
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