Background
From self-reliance to good governance
Partnership in the health sector
Conceptualizing partnerships
Methods
Study context
Data collection and analysis
Participation in the meetings on P4P
Policy documents
In-depth interviews (IDIs)
Agency/Organization | Interviews |
---|---|
Ministry of Health and Social Welfare- Tanzania | 2 |
World Bank – Tanzania | 1 |
Ministry of Foreign Affairs – Norway | 1 |
The Royal Norwegian Embassy – Tanzania | 1 |
Norad | 1 |
Danida | 1 |
Irish Aid | 1 |
GiZ Tanzania | 2 |
Swiss Agency for Development and Cooperation | 1 |
Clinton Health Access Initiative (CHAI) | 2 |
Research ethics
Results
High political pressure
[Former] Prime Minister Stoltenberg of Norway and President Kikwete of Tanzania met in 2007, so as you can see the engagement was at a very high level regarding P4P. After this meeting we were requested to support the health sector [through P4P] in Tanzania, but prior to this, the embassy wasn’t really visible in the health sector in Tanzania. (Staff, Royal Norwegian Embassy, Dar es Salaam)
We were raising some questions around P4P since we had a feeling that the treatment was prescribed before the diagnosis, because they said let’s do P4P in Tanzania. Really, without even looking at what are the barriers to the quality of services, to the delivery of services and so on and so forth, but the recipe was already coming, and we quietly and quickly realized that we cannot maneuver much outside this P4P thinking. (Official, Norad)
The primary problem that we are facing in Tanzania is a health system that isn’t working well. If you think of the six building blocks of a health system, all those, including financing, infrastructure, health management information systems, among others, P4P could have worked well if all these blocks were functioning well, so around P4P you need to get the system working well for desired results. (Official - Ministry of Health and Social Welfare, Tanzania)
The thing is that there is political drive and political push to go for that [P4P] and this political push comes from Norway and therefore the government [of Tanzania] was not in a position to say no despite that the basic foundations to support P4P, either at health facilities or in the health system were not available. (Official, Danida)
People were saying we are not achieving enough and we were mainly concerned that we might not reach targets for health related MDGs, especially goals 4 and 5. Because of this we were thinking of a way to accelerate progress towards these targets. (Official - Ministry of Health and Social Welfare, Tanzania)
The Norwegian government wanted to go into countries that were really struggling with child mortality as well as infant mortality, and so countries were picked according to that. India was one, and then Pakistan was chosen, and then there was a need for some countries in Africa. Tanzania became the obvious choice, because it is a relatively easy country to work in, in terms of stable political conditions, and also quite strong leadership, with a strong President. (Official, Norad)
Conflicts and changing alliances in the health basket fund
Norad was just rejoining the health basket at the time when we introduced the P4P agenda. People did not approve of that, especially coming with such an agenda of P4P, some of the donors were totally against it, like the Danes, they were appalled by it both politically and otherwise. Even the World Bank and USAID could not come openly to support us for fear of a backlash. The Dutch were furious, saying we were not serious, calling us names, and saying we were trying to hijack the Health Basket Fund. (Official, Norad)
The government’s position back then was that there were too many pilots in the country and if there was going to be anything it has to go full-scale. A pilot would mean that one district or region would benefit. Tanzania has a strong feeling about equity issues, you know from our history, and because of this the government was determined to go ahead with a full-scale implementation. (Official - Ministry of Health and Social Welfare, Tanzania)
P4P came with pressure such that the government was forced to go full scale with P4P. Yet the system was not ready and it didn’t function and the basket partners said we cannot do it. We pulled out and did not finance that. This was a real blow because it created tensions between basket partners and the government. I really feel sorry. We lost valuable time, energy and confidence in this process. (Official, Swiss Development Cooperation)
The World Bank is now putting P4P as a condition for funding the basket. P4P may not be bad as such, but we would expect the Bank to come with a lot of expertise and negotiate with all the partners to get that [the agenda] through, but it was not exactly like that. It was discussed with the partners but I am not sure if there was broad consensus on this approach. It was pushed on the Basket and now we have to make the best of it. (Official, Swiss Development Cooperation)
Building consensus
Things were not very clear when P4P was introduced. People needed more understanding of the design and operations of the program, which was not readily available. Many were skeptical of the design, so Norway, which is one of the members in the Basket, asked if we could look more into the concept and this is how the pilot came about. Now as we do these assessments, we see that more donors are coming in and a taskforce for P4P has been formed by the Ministry and we have partners like USAID, the World Bank and Norway, the Germans. Also the chair of the basketeers [Irish Aid at the time] is being co-opted. (Official, World Bank Tanzania)
There is an emerging consensus that P4P needs to be viewed within the broader health systems reforms…there is need to make sure facilities receive essential medicines in time, are well equipped and meet minimum staffing standards so that they can perform and deliver quality services. [Former Minister of Health and Social Welfare, Tanzania [42]]