Functionality of primary health facility governing committees in implementing direct health facility financing in Tanzanian local government authorities
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Date
2022
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Sokoine university of agriculture
Abstract
The Alma Ata Declaration of 1978 identified community participation in health service
delivery as a cornerstone component for improving Primary Health Care (PHC). Therefore, it
advocated for providing opportunities for health service users/communities to directly
participate in the designing, implementation and monitoring of healthcare facility operations.
To incorporate communities in the planning, implementation and evaluation of primary health
care services, community governance structures known as Health Facility Governing
Committees (HFGCs) were established in Lower and Middle-Income Countries (LMICs).
These HFGCs are composed of community members devolved with powers and functions of
representing the community in the governance of health service delivery in primary health
care facilities (PHCF). There have been continued efforts to strengthen community
participation through having functional HFGCs to improve health service delivery in PHCF
through decentralization. The fiscal decentralization is the reform currently adopted by many
LIMCs countries to empower both community governance structures and service providers
in improving health service delivery at the PHCF.
Tanzania, like other LIMCs countries, is implementing fiscal decentralization through Direct
Health Facility Financing (DHFF) to empower service providers and deepen the community’s
participation in the planning, implementing and monitoring PHCF to improve health service
delivery. However, the status of the HFGCs' functionality in accomplishing their assigned
powers and responsibilities under DHFF is not known. This study was conducted to assess
the functionality of HFGCs under the DHFF context in selected Tanzania Local Government
Authorities. Specifically, the study assessed (i) the functionality level of HFGC in primary
public health facilities under DHFF; (ii) the accountability of HFGCs in the public primary
health facilities under DHFF and (iii) the perceived factors determining the functionality of
HFGCs under DHFF.
A cross-sectional research design was used in which both qualitative and quantitative data
were collected simultaneously or at one data collection phase to assess the performance of
HFGCs. The sampling of the regions, councils and health facilities is based on the President
Office-Regional Administration and Local Government's Star Rating Assessment of the
performance of all public primary healthcare facilities in Tanzania, which was accomplished
at the beginning of 2018, that is, the same year DHFF started. The sample size for this
investigation was determined using a four-stage multistage cluster sampling process. In the
first stage, four regions were purposefully chosen based on their performance (two regions
high and two low performance). From each region chosen in stage one, two councils were
chosen in the second round. One of the two councils chosen had a low and another with high performance in the area based on the star rating assessment. Four health facilities
were purposively selected from each council selected. Two health facilities were chosen
because of their low and other two health facilities because of the high performance in the
council. The location of the facility and council was also a criterion to accommodate the
diversity of the council and health facilities. In stage four, respondents for the structured
questionnaire were selected proportionally from each HFGC in which the response was 280
respondents. Respondents for interview and focus group discussion were purposively
selected. The participants were chosen for interviews and focus group discussions (FGDs)
based on their ability to provide relevant information about the performance of HFGCs under
DHFF. Therefore, for a respondent to be included in the interview and FGDs was supposed
to be a member of HFGC implementing DHFF. The point of saturation determined the
number of interviews and FGDs.
The closed-ended structured questionnaire was used to collect quantitative data from each
selected member of the HFGCs. The Open Data Kit (ODK) software was used to develop
the data gathering software (database). To collect data, a quantitative approach based on
mobile data collecting (MDC) was used. Data were captured via mobile phones and then
transferred to a central server. The response rate for HFGCs who filled out the questionnaire
was 280 respondents. Qualitative data were collected through interviews and FGDs. In-
depth interviews were conducted with HFGC chairpersons to examine the extent they have
been accomplishing the HFGC mandates under DHFF settings. On the other hand, FGDs
were conducted with other members of HFGCs excluding the HFGC chairpersons.
Quantitative data were coded, processed and analysed by using IBM-SPSS v. 25. In
assessing the functionality of HFGCs under DHFF context, Descriptive and inferential
statistics were used to analyse data. A binary logistic regression model was employed to
determine factors associated with HFGC functionality. To assess the accountability of
HFGCs under DHFF implementation, the descriptive statistic and binary logistic regression
were employed based on the HFGCs accountability index or predictors of accountability. To
assess the perceived factors determining the performance of HFGCs, Relative Importance
Indices (RII) within Multiple regression were employed.
The findings from this study HFGC functionality under DHFF was found to be good at 78.57
%. Specifically, 87.14 % of HFGCs were found to have good functionality in mobilizing
communities to join Community Health Funds, 85 % were good at participating in the
procurement process, 81.43 % were good at discussing community health challenges and
80% were good at planning and budgeting. However, there was a difference in functionality
among HFGCs, with HFGCs from primary health facilities that indicated a high-performance
during star rating assessment in 2018 having relatively good functionality, scoring 79.45 %, as opposed to HFGCs from primary health facilities that had a low performance, scoring
73.88 %. Regarding accountability, the HFGCs indicated good performance scoring 78 %.
HFGCs were found to have a high level of accountability in terms of encouraging the
community to join community health funds (91.71%), participating in receiving medicines and
medical commodities (88.57%), and timely provision of health services (84.29%). The
HFGC's responsibility was shown to be substantially associated with the health planning
component (p=0.0048) and the financial management aspect (p=0.0045). Furthermore, the
study found that the factors which are more important for the functionality of HFGCs are the
availability of finance to the health facility with RII 0.8964 score which ranked the first
important determinant of HFGC performance, followed by the clarity of powers and functions
with RII 0.8928 score, as second important determinant, and communication between the
HFGCs and community with RII 0.8792 score, as a third important determinant.
The reality from the findings of this study on fiscal decentralization through DHFF in selected
HFGCs supports the idea that decentralization empowers subnational health actors since
the performance of HFGCs in health facilities implementing DHFF was found to be good.
This study implies that the setting and how fiscal decentralization is implemented are critical
for determining whether or not it empowers actors. Therefore, for HFGCs to be empowered
and be able to better perform their duties and responsibilities, the context and the
characteristic of HFGC member are key determinants. It is therefore recommended that, the
government review educational level for the members of HFGCs, timely transfer funds to the
health facilities, conduct comprehensive training to the members of the HFGCs on how to
carry out their functions and increase the number of prime vendors.
Description
Thesis
Keywords
Performance, Health Facility, Governing Committees, Direct Health Facility, Financing, Fiscal Decentralization