Background
Introduction
Conceptual background
Methods
Results
Public-private partnership and governing bodies: Challenges and limitations
“I have heard of the CHSB, but I don’t know what is usually discussed. We don’t have a representative. We (private providers) are considering forming an association and then appoint leaders, who would then be our representatives. But we have not yet managed to form that association” (Participant 21 – Bagamoyo 2014).
“There was one person from this ward who completed the application form for board’s membership, and we (ward officials) did approve it…Those positions (to be a CHSB member) are advertised and forms are usually made available at ward offices…It is very difficult to forward negative comments…The only time we can deny an individual this position is when that person is mentally not normal” (Participant 20 – Bagamoyo 2014).
“The relationship with private providers is not well perceived by the public. There is a perception that they (public and private staff) favour each other. The main argument is items are embezzled from the public facilities, and get sold in private facilities” (Participant 23 - Bagamoyo 2014).
“The big role of the CHSB is to control procurement and distribution of drugs and other medical supplies at public facilities. The linkage between other committees and the CHSB is on how public complaints are conceived at lower levels and how they get channelled to the CHSB” (Participant 25 - Bagamoyo 2014).
“I would say our committee (Ward Health Committee) is non-functional, completely non-functional since last year. We tried to revive it but there were complaints among members about general skills development” (Participant 20 – Bagamoyo 2014).
“There are a lot of issues that we don’t know. We are only two of us (me and the in-charge of the public facility in the village) who attended training at the district, and it was a brief session. You cannot grasp everything in such a short training” (Participant 24 – Bagamoyo 2014).
Strategic decisions to improve responsiveness: Limited inclusion of actors in planning and decision-making
“I used to attend strategic meetings back in early 2000s as a representative of (non-state actors) but after I took another job I stopped. So if you tell me I am still a representative, that is not right, I don’t attend those meetings…” (Participant 1 – Bagamoyo 2014).
“I usually hear about it (CCHP). I have never seen a copy…I don’t understand why my name should appear in that document as a representative” (Participant 9 – Bagamoyo 2014).
“We (CHMT and CHSB) can make our decisions at the district level after receiving guidelines from the ministry however, for CHF members to receive services from private providers we need to plan it well. We have to get them (private providers) sensitized. For now we have no options” (Participant 17 – Bagamoyo 2014).
“In one activity you may find you have twenty indicators. For example under DHMIS there are about eight reports. At the same time there are other reports required for each section such as RCHS, PPP, etc… this becomes an additional workload. There is no way you can get a good quality report” (Participant 18 – Bagamoyo 2014).
“The government needs to find a way to support us. They (government) see our monthly reports. In a month, a number of under-fives attended here is between 1000 and 2000, new cases of pregnant mothers is between 70 and 80, leave alone ‘re-attendance’. For family planning, we report 200 clients. That is a very tough job…We really struggle to get staff. And I understand even at government facilities there is a shortage, but there are ways we can work together on this” (Participant 21 – Bagamoyo 2014).
“There are times you may receive the new stock from the Medical Store Department but since it is a fixed stock you may be in a situation where there is an increased need for a particular treatment. In such a situation it becomes very difficult to approach the company (the partner) for assistance…” (Participant 30 – Bagamoyo 2014).
Performance accountability: Poor performance of accountability structures
“There is no feedback provided once we have submitted our reports. We don’t discuss anything further. When you see the performance of Bagamoyo District as a whole, you just assume you were part of the success/ failure…and it is only when you are lucky to attend higher level meetings” (Participant 3 – Bagamoyo 2014).
“We are accountable to the pharmacy council, as we submit our monthly reports to them…things like family planning are included. So they get that information straight from us…and how they use it is up to them” (Participant 12 – Bagamoyo 2014).
Contractual governance: Lack of service level agreements
“A General MoU does exist… The partnership is more research project-oriented…a laboratory was constructed for the project… the scope of collaboration is oriented towards the fund committed to the project” (Participant 6 – Bagamoyo 2014).
“There are those services/ programs with contracts, for example those who get funds from outside the country… Programs that are funded by the local government usually do not have contracts” (Participant 23 – Bagamoyo 2014).
Type of Providers | Type of Contractual Agreement | Type of Collaboration |
---|---|---|
Faith-Based Provider | None | Provision of RCHS but excludes family planning. Supplies are provided free of charge, and staff are seconded from local government. In return services offered are free of charge. |
Faith-Based provider | None | Informal arrangements at village level for staff availability. |
Faith-Based provider | None | Informal arrangements between public facilities, and the private provider such as transfer of vaccines from one facility to the other during power blackout. |
PFP and PNFP providers | None | Informal arrangements for assistance when a public facility runs out-of-stock such as for syringes, gloves, etc. Such assistance is usually free of charge but at times a replacement has to be sent at a later stage. Some private providers receive reagents for Voluntary Counselling and Testing (VCT) services. |
Private pharmacies and faith-based providers | General Contract | Contractual arrangements between the National Health Insurance Fund (NHIF) and private providers, but restricted to pharmacies and faith-based providers. ADDO and private for profit are not part of providers’ network. |
Maternity home | None | Various forms of PPP arrangements with the maternity home such as outreach- point for immunization, free of charge supplies for some RCHS including Prevention of Mother to Child Transmission of HIV (PMTCT) however, services are not entirely free, clients have to contribute and the contribution is determined by the provider. |
Jointly operated facility, private estate company and government | None | The company provided a building, house for seconded staff, employ some staff, and procure and maintain a stock for its employees, while the government provides, supplies through its Integrated Logistics System for the community, and overall oversight of the facility, and second staff. RCHS are provided as per government guidelines. |
Traditional Birth Attendant (TBAs) | None | There are some of facilities that have introduced incentives for TBAs who facilitate referrals of pregnant mothers for facility delivery. |
NGOs/ Private company | MoU | Partnership with NGOs (at local or national levels) in construction of staff houses, renovation of facilities, sexual and reproductive health initiatives, and HIV/AIDS prevention care and treatment initiatives. |
Parastatal-based facilities | None | Parastatal-based facilities now operating like public facilities. Initially they had their own arrangements managed through their respective Ministerial headquarters. |
Research Institute | MoU | Research project-oriented collaborations. The partnership is initiated at a time when the project is commissioned, and ends at the end of the project. It may involve construction and renovation of buildings, operating, and then transfer. |
Out sourcing | None | In case of out-of-stock at the Medical Store Department. The district procurement officer would purchase a new stock from the appointed contractor, though the contractor tends to change each year. |
“Occasionally, I have supported the district hospital with drugs when they run out of stock… We are not getting anything from the Medical Store Department (MSD). We buy our supplies from a wholesaler, but issue them free of charge. We also give to the district hospital for free” (Participant 3 – Bagamoyo 2014).
“With private providers, there is a challenge as there are those who provide incomplete data, and those who do not respond. For example data on HIV, we need that information as they (private providers) get subsidized reagents from the government, but you will find that they (private providers) provide incomplete information claiming that they buy other items using their own resources” (Participant 8 – Bagamoyo 2014).
“…because we do not receive supplies from the government, it is a problem. There are situations when we get stuck, and we notify our clients/patients (including those under NHIF) to contribute… It is difficult to run a facility if you buy something at TSH 20,000/- and be expected to sell it at TSH 3,000/-…” (Participant 29 – Bagamoyo 2014).
“We are building (additional buildings for new RCHS) slowly, as the revenue that we get we have to distribute it to salaries, buying medical supplies and drugs, as well as food for staff. We are doing it slowly” (Participant 27 – Bagamoyo 2014).
“I have heard of service level agreement. We did discuss this in this process of establishing RCHS, because we wanted staff to be seconded here, and we were ready to provide housing and allowances” (Participant 16 – Bagamoyo 2014).