Private Health Sector Assessment in Tanzania

By James White, Barbara O'Hanlon, Grace Chee and 6 more

Mainland Tanzania exemplifies the developing world's struggle to achieve middle-income status while confronting widespread poverty and substantial health challenges. Tanzania's struggle with HIV/AIDS, reproductive and child health, malaria, and tuberculosis are characterized by both positive recent trends and persistent challenges. A high disease burden coupled with finite public sector resources has led the government of Tanzania to increasingly seek innovative tools to protect the health and wellbeing of its citizens. Previous reform efforts have included decentralizing decisionmaking authority to local governments to improve the responsiveness of public sector programs and partnering with faith-based health facilities to expand the government's reach into rural areas. In recent years, the government has increasingly tried to leverage the private health sector's capacity to strengthen the Tanzanian health system—first by removing the ban on private practice in 1991 and then by emphasizing PPPs in its national health policies and strategic plans. In response, the private health sector has grown and organized into several umbrella organizations, such as the Christian Social Services Commission (CSSC), the Association of Private Health Facilities in Tanzania (APHFTA), and the National Muslim Council of Tanzania (BAKWATA). Together, the public and private sectors have laid the policy groundwork for improved collaboration. Engaging the private sector beyond dialogue and operationalizing PPPs has proven more difficult due to lingering distrust and a lack of communication between the sectors at lower levels. Currently, the private health sector is actively involved in the delivery of key health services, especially related to family planning, child health, and malaria. However, there are numerous private health sector providers and other actors that the Tanzanian government can better leverage to relieve the burden on public sector resources and produce better health outcomes for all Tanzanians. This assessment makes several recommendations to eliminate current obstacles, especially around the areas of the policy and governance, health financing, service delivery, pharmaceutical procurement, and human resources for health.

• Language: English
• Publisher: World Bank Publications
• Release date: Oct 29, 2013
• ISBN: 9781464800429

James White

James White lived in Northern Ireland. He was a popular writer of science fiction for over forty years. He was best known for his twelve novels in the Sector General series, beginning with Hospital Station. He died in 1999.

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A WORLD BANK STUDY

Private Health Sector Assessment in Tanzania

James White, Barbara O’Hanlon, Grace Chee, Emmanuel Malangalila, Adeline Kimambo, Jorge Coarasa, Sean Callahan, Ilana Ron Levey, and Kim McKeon

© 2013 International Bank for Reconstruction and Development / The World Bank

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ISBN (paper): 978-1-4648-0040-5

ISBN (electronic): 978-1-4648-0042-9

DOI: 10.1596/978-1-4648-0040-5

Cover photo: Dr. Frank Lyaruu and an assistant review lab work at his private facility in Arusha, Tanzania. © Sean Callahan

Library of Congress Cataloging-in-Publication Data

White, James, 1980- author.

Private health sector assessment in Tanzania / James White, Barbara O’Hanlon, Grace Chee, Emmanuel Malangalila, Adeline Kimambo, Jorge Coarasa, Sean Callahan, Ilana Ron Levey, and Kim McKeon.

p.; cm. — (World Bank studies)

Includes bibliographical references.

ISBN 978-1-4648-0040-5 (alk. paper) — ISBN 978-1-4648-0042-9

I. World Bank, issuing body. II. Title. III. Series: World Bank studies. [DNLM: 1. Delivery of Health Care—Tanzania. 2. Private Sector—Tanzania. 3. Quality Assurance, Health Care—Tanzania. W 84 HT3]

RA399.T34

362.109678—dc23

2013022868

Contents

Acknowledgments

The assessment team is very grateful for the continued support from the Tanzania Ministry of Health and Social Welfare and the Tanzanian Public-Private Partnership Technical Working Group (PPP-TWG). In particular, the team would like to thank Permanent Secretary Regina Kikuli, Dr. Edwin Mung’ong’o, Dr. Kiangi, Mariam Ally, and Dr. Mariam Ongara for their assistance and support throughout the assessment process. The team would also like to thank Dr. Adeline Kimambo and Dr. Emmanuel G. Malangalila for their contributions in the preparation and stakeholder interview stages of the assessment, as well as Erick Msoffe for his coordination of logistics during the assessment. Numerous individuals gave of their time to provide information through key informant interviews. We are extremely grateful for the input and insight we received from individuals at various ministries, health facilities, and organizations, including the following:

• National Government: Ministry of Health and Social Welfare, PPP-TWG, Quality Assurance Unit, Health Financing TWG, Tanzania Commission on AIDS (TACAIDS), Pharmaceuticals, Commodities, Infrastructure and Food Safety TWG, Reproductive and Child Health Vertical Program, National Malaria Control Program, National AIDS Control Program

• Regional Government: Coast Region Regional Health Management Team (RHMT), Kibaha Rural Council Health Management Team (CHMT), Kibaha Township CHMT, Mkuranga CHMT, Arusha RHMT, Arusha CHMT, Kilimanjaro RHMT, Moshi CHMT

• Director General Dr. Marina Njelekela of Muhimbili National Hospital

• Medical Council of Tanzania

• Nurses Council of Tanzania

• Private Nurses and Midwives Association of Tanzania

• Medical and Laboratory Scientists Association of Tanzania

• Pharmacy Council of Tanzania

• Tanzania Food and Drugs Authority

• Tanzania Medical Stores Department

• Association of Private Health Facilities in Tanzania (APHFTA) and APHFTA Northern Zone

• Mission for Essential Medical Supplies and Services

• Tanzania Christian Social Services Commission

• Health center staff from numerous private sector facilities

• Nongovernmental and civil society organizations

• Doctors in private practice

• Private pharmacies

• Private insurance companies

• Private health care businesses

• Medical training institutions

Abbreviations

Executive Summary

Country Context

Tanzania exemplifies the developing world’s struggle to achieve middle-income country status while confronting widespread poverty and substantial health challenges—such as persistently high child and maternal mortality, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria. Over 74 percent of mainland Tanzania’s 41.9 million people live in rural areas where, despite strong national economic growth over the past decade, income levels remain among the lowest in Africa and an estimated one-third of Tanzanians live in abject poverty. Stable leadership, strong political will, significant international donor support, and Tanzania’s standing as one of the fastest growing economies in East and sub-Saharan Africa (with a five-year average real gross domestic product (GDP) growth rate of 6.9 percent 2006–11)—have not translated into improved health or social outcomes for the average Tanzanian. Malaria remains a leading cause of morbidity and mortality, costing an estimated US$240 million every year in lost GDP. An HIV/AIDS prevalence rate of approximately 5.6 percent among adults aged 15–49 years translates into an estimated 1.4 million people living with AIDS—with an additional 105,000 new infections and 85,900 AIDS-related deaths annually. High infant and under-five mortality (50/1,000 and 108/1,000, respectively), only three in 10 mothers receiving postnatal care, and a consistently high maternal mortality rate of 454 out of every 100,000 live births suggest substantial barriers to health access and effective service delivery. However, despite these challenges, the Government of Tanzania (GOT)—now implementing its Health Sector Strategic Plan (HSSP) III (2009–15)—has made strides in improving the delivery of essential health services. HIV prevention efforts have reduced prevalence from 7.3 percent in 2000 to 5.6 percent in 2009; prevention of mother-to-child transmission coverage was estimated at close to 59 percent in 2011; and a strong multipronged malaria prevention and treatment strategy has significantly improved access to first-line malaria therapy throughout the country.

In seeking to sustain and intensify these gains, the GOT has become a regional leader in acknowledging the benefits of leveraging private health sector capacity and resources to address national health challenges and realize the objective of country-owned health responses. However, despite a relatively well-developed policy environment for public-private collaboration in health, the process and methods for operationalization of private sector engagement and public-private partnership (PPP) are not well known. This has significantly limited actual implementation of public-private collaboration within the health system, with continuing missed opportunities to strengthen Tanzania’s health system through enhanced engagement and mobilization of private sector resources in health.

Purpose of the Assessment

In this context, Tanzania’s National PPP Policy and HSSP II included a call for a private health sector assessment. Accordingly, following a regional technical exchange in Mombasa, Kenya, Tanzania’s Public-Private Partnership Technical Working Group (PPP-TWG) requested that the Health in Africa (HIA) initiative of the International Finance Corporation (IFC) conduct an assessment of the private health sector in mainland Tanzania. Given a history of collaboration between HIA and the USAID-funded project Strengthening Health Outcomes through the Private Sector (SHOPS), which has included holding regional technical workshops on private sector engagement that have drawn representatives from over 14 African countries, HIA engaged SHOPS to lead the effort. With funding support from HIA and the USAID Office of HIV/AIDS, SHOPS assembled a nine-person assessment team composed of health system experts from IFC, SHOPS, USAID, and local stakeholder organizations.

Adopting Tanzania’s relatively well-developed PPP policy framework as the basis for a preparatory dialogue, USAID/Tanzania and the PPP-TWG underscored the importance of highlighting the challenges that limit private sector involvement in health and inhibit PPP reforms, with the ultimate purpose of assisting the PPP-TWG and other stakeholders in developing a prioritized agenda for more effective private health sector engagement and PPP-focused health sector reforms within the context of the Tanzanian health system. The broad focus of the assessment was the status of existing PPPs within the Tanzanian health system, with specific attention also to the opportunities for operationalizing improved private health sector engagement in the key health areas of HIV/AIDS, malaria, TB, and reproductive and child health (RCH)—specifically related to the policy-making process, health financing, and service delivery.

Methodology

The private health sector assessment (PSA) team comprised four health systems and private sector experts representing the SHOPS project and HIA initiative. Additionally, two Tanzanian health system experts were involved during the preparatory, data collection, and analysis phases of the assessment. A comprehensive desk review of existing literature, combined with secondary analysis of Demographic and Health Survey, AIDS Indicator Survey, and National Health Accounts data, were conducted in order to promote efficiency and inform the assessment focus and strategy prior to the initiation of field work in country. From May 21 to June 1, 2012, the PSA team conducted key stakeholder interviews in mainland Tanzania with over 160 individuals from nearly 90 different organizations representing the public, private for-profit (PFP), and private not-for-profit (PNFP) sectors. The team conducted interviews at facilities at all levels of the health system, as well as with private sector umbrella organizations, government bodies and officials, faith-based and nongovernmental organization (FBO/NGO) leadership, private insurance companies, and a wide range of additional stakeholders. Interviews were conducted in