Local Government Reform Programme Embedding Decentralisation by Devolution Across Government

Transcription

1 Prime Minister's Office - Regional Administration and Local Government Government of United Republic of Tanzania Local Government Reform Programme Embedding Decentralisation by Devolution Across Government Assessment Report for Ministry of Health and Social Welfare Final Draft January 2007

2 Prime Minister's Office - Regional Administration and Local Government Government of United Republic of Tanzania Local Government Reform Programme Embedding Decentralisation by Devolution Across Government Assessment Report for Ministry of Health and Social Welfare Final Draft January 2007

3 Table of Contents 1 Introduction The assignment The health sector General Approach Organisation of Report 3 2 Ministerial Profile The Role and Functions of Ministry Status of D by D Prior to Assessment Human Resources Management 6 3 Specific Approach and Methodology Specific Approach Documents Detailed Methodology 9 4 Assessment and Findings Assessment and Analysis Criteria Assessment and Analysis Matrices Assessment Findings General observations from Assessment 14 5 Conclusion and Recommendations Conclusion Specific recommendations General Recommendations 23 Annexes: Annex 1: List of Participants Annex 2: Assessment Matrix Annex 3: MTEF activities Annex 4: MTEF activities to be devolved to LGAs

4 Assessment Report for Ministry of Health and Social Welfare ii Abbreviations and Acronyms ACT - Artemisia Combination Therapy ADDO - Accredited Drug Dispensing Outlet ANC - Ante Natal Care ARH - Adolescent Reproductive Health ART - Anti- Retroviral Treatment ARV - Anti- Retro-Viral ASRH - Adolescent Sexual Reproductive Health BCC - Behavioural Change Communication BFC - Basket Financing Committee CBMIS - Community Based Management Information system CBRCHS - Community Based Reproductive and child Health Services CCHP - Comprehensive Council Health Plan CG - Central Government CGLA - Chief Government Laboratory Agency CDTI - Community Directed Treatment - Ivermectin CHBC - Community Based Health Care CHF - Community Health Fund CHMTs - Council Health Management Teams CHSB - Council Health Service Board CMO - Chief Medical Officer CNO - Chief Nursing Officer CTU - Central Transport Unit D by D - Decentralization by Devolution DDH - District Designated Hospital DHS - Director of Hospital Services DLDB - Duka La Dawa Baridi DMO - District Medical Officer DOTS - Directly Observed Treatment Short Courses DLDM - Duka la Dawa Muhimu DPS - Department of Preventive Services DRF - Drug Revolving Fund DSS - Demographic Surveillance Stations EMOC - Emergency Obstetric Care EPI - Expanded Programme on Immunization EPR - Emergency Prepared Response FACS - Elllfeederfac FTC - Full Technician Certificate FGM - Female Genital Mutilation GMP - Growth Monitoring and Promotion GoT - Government of Tanzania HAM - Huduma ya Afya ya Msingi

5 Assessment Report for Ministry of Health and Social Welfare iii HMIS - Health Management Information System HIV/AIDS - Human Immune Virus/ Acquired Immune Deficiency Syndrome HRUTF - Health Research Trust Users Fund HSR - Health Sector Reform IDSR - Integrated Disease Surveillance Response IEC - Information, Education and Communication IMCI - Integrated Management of Childhood Illnesses LGAs - Local Government Authorities MoAFSC - Ministry of Agriculture and Food Security MCH - Maternal and Child Health MoEVT - Ministry of Education and Vocational Training MDR - Multi- Drug Resistance MDT - Multi- Drug Therapy MoLD - Ministry of Livestock Development MoF - Ministry of Finance MoHSW - Ministry of Health and Social Welfare MPEE - Ministry of Planning, Economy and Empowerment MSD - Medical Stores Department MTEF - Medium Term Expenditure Framework MTUHA - Mfumo wa Utoaji Taarifa za Afya NCCIDD - National Council for Control of Iodine Deficiency Disorders NCDRD - Non Communicable Diet Related Diseases NCD - Non- Communicable Diseases NIMR - National Institute for Medical Research NRRT - National Rapid Response Team NSHP - National School Health Programme NSS - National Sentinel Surveillance OHS - Occupational Health Services ORCI - Ocean Road Cancer Institute ORET - Overseas Related Trade OVC - Orphan and Vulnerable Children PAC - Post Abortion Care PHC - Primary Health Care PLWAS - People Living with AIDS PLWHAS People Living with HIV/AIDS PMTC T - Prevention from Mor to Child Transmission POM-RALG - Prime Ministers Office Regional Administration and Local Government PO- PSM - Presidents Office Public Service Management PWD - People Living with Disabilities RCHCO - Reproductive and Child Health Coordinator RCHS - Reproductive and Child Health Services RHMTs - Regional Health Management Teams

6 Assessment Report for Ministry of Health and Social Welfare iv SHM - Strengning Health Management SOP - Standard Operational Procedure STI - Sexually Transmitted Infections TA - Technical Assistance TANHER - Tanzania Health Research TB - Tuberculosis TFDA - Tanzania Food and Drug Authorities TFNC - Tanzania Food and Nutrition Centre TIKA - Tiba kwa Kadi TIMS - - Transport Management Information System TPHA - Tanzania Public Health Association VAH - Voluntary Agency Hospital VCT - Voluntary Counselling and Testing WFP - World Food Programme

7 Assessment Report for Ministry of Health and Social Welfare 1 1 Introduction 1.1 The assignment The present report is part of an assessment exercise undertaken on to principles of Decentralisation by Devolution (D by D) in five ministries. Under principles of D by D Central Government (CG) is responsible for policy formulation, provision of a regulatory framework, standards setting, inspections, monitoring and auditing. The Local Governments are responsible for service delivery. The CG has furr a responsibility of creating an enabling environment for LGAs to carry out ir mandated responsibilities. The Government of Tanzania (GoT) has embarked upon D by D process through its Local Government Reform Policy of The GoT remains committed to reforming Local Government Authorities (LGAs) and transfers decision-making powers, functional responsibilities and from CG to LGAs. Although some progress have been made in devolving functions and responsibilities, Chief Secretary instructed that furr efforts should be made to devolve activities appropriate to local governments along with financial, human and or. It was agreed that most effective way of assessing current situation of devolution process was to examine ministries Medium Terms Expenditures Frameworks (MTEFs). The assessment was to determine if MTEFs included activities and attendant resource which in a system of D by D should be under responsibility of local governments and reflected in grant allocation to respective LGAs. The assessment was undertaken in Ministries of Agriculture, Food Security and Cooperatives; Education and Vocational Training; Health and Social Welfare; Infrastructure Development and Water. Similar ministerial assessment reports have been completed for each of or four ministries. A Main Assessment Report has been prepared which presents broader background, approach, main finding and conclusions and recommendations of Assessment. It is recommended that Main Assessment Report is read prior to present report in order for reader to properly understand context of assignment. The sector specific ministerial reports, like present report, bring considerable sector information and analysis, but are not exhaustive on ir own in terms of comprehensive presentation of D by D concept.

8 Assessment Report for Ministry of Health and Social Welfare The health sector The Ministry of Health and Social Welfare was established late December, 2005 with overall objective to provide health and social services in order to improve and sustain quality of life and social well-being of people. Tanzania, for several decades now, has faced dual burden of a crisis in public health and grave shortage of. The health challenges inherent in se crises are: spread of deadly diseases and problems such as malaria, HIV/AIDS pandemic, tuberculosis, malnutrition and anaemia. The effects of se devastating epidemics are exacerbated by conditions of poverty and its attendant vicious circle. Thus, while ir poverty makes m more vulnerable to effects of ill-health and less able to afford proper treatment, succumbing to sickness in turn reduces ir already meagre capacity to generate income. This situation makes it necessary for Government to provide free health and social welfare services to majority of poor. As a pro-poor sector, it attracts substantial amount of (financial, human and materials) from national budget. Despite high demand for, health sector per capita allocation is only 6-8 USD. Hence, more injection of to Health Sector and in particular financial is absolutely essential. The experience of Tanzania Essential Health Interventions Project (TEHIP) suggests, however, that sudden injection of funding alone will not necessarily solve health care crisis facing country. But certainly funding for health systems and health interventions must increase substantially gradually. What requires to be done is to work out policies and strategies that will generate interventions which will enable health planners at both national level and LGAs level to allocate health in a strategic way in order to target real and prevailing needs. The efficiency of health system and appropriateness of strategies in health care is key to translating health care spending into an increase in health gains. The success of Health Sector hinges on partnership with LGAs and rational allocation and distribution of within sector between Ministry, LGAs and or Health Services Providers. Therefore, policy implications one draws from above challenges is that institutions and agencies concerned with improving current grim health outlook in Tanzania must take a more systemic approach of turning attention to apparently mundane issues within health system such as infrastructure, training, capacity building, human and health planning. Pervasive infectious diseases, high rates of infant mortality and wide spread disability call for innovative strategies and policies to improve health services to Tanzania. The health care crisis described above, occurred despite longstanding policies that had placed health care high on national agenda. Since independence, government sought to ensure that all citizens had access to education, health care and clean water as a way of fighting three enemies: poverty, ignorance and diseases. These efforts produced significant achievements in health sector as evidenced by declining infant mortality rates, maternal mortality rates and or debilitating ailments once widespread in country. It can refore be argued that success of MKUKUTA and Tanzania s attainment of Millennium Development Goals

9 Assessment Report for Ministry of Health and Social Welfare 3 will depend to a large extent on performance of health sector. Bold initiatives are required to address problem of inadequate and rising trend of infectious diseases like tuberculosis, HIV/AIDS, malaria and etc. Bold initiatives are also required to furr efforts of entrenching principles of decentralisation by devolution throughout health sector, and particularly allocation and distribution of between Ministry of Health and Social Welfare, LGAs and or Health Service Providers in Private Sector. To that effect assessment of Ministry s MTEF was initiated. 1.3 General Approach A team of independent facilitators was mobilised to lead assessment exercise in each of five ministries. For each of ministries Task Teams consisting of one representative from PMO-RALG, two representatives from relevant ministry and an independent facilitator was organised (see Annex 1 for participants in MoHSW assessment). The general approach embarked upon was a participatory review of ministries MTEFs and scrutiny of development and recurrent budgets, with purpose of assessing which activities and attendant should be devolved to LGAs and which should remain at CG level. A specific Assessment Matrix (see Annex 2) was used in order to record all important information and allow for easy verification by all stakeholders. Discussions were held with Senior Management and substantial literature review on sectors was also undertaken. The outcome of this assessment will inform next budget guidelines preparation which is expected to include detailed references to activities to be devolved. The assessment exercise and outcome as presented in this Report are intended to provide a comprehensive review and analysis of allocation in MoHSW. It is intended to determine to which extent such allocation internalizes principles espoused in Government Policy of Decentralisation by Devolution and as clearly stipulated in Policy Paper of 1998 on Local Government Reform (LGR). As it is difficult to provide adequate information on LGR and principles of D by D in this Report, Reader is advised to refer to Policy Paper, Strategy developed for Embedding Decentralisation by Devolution across Government (PMO-RALG 2006) for more detailed discussion and exhaustive treatment of conceptual definition of this important subject. It has already been mentioned that Main Assessment Report is a prerequisite to read before continuing with this ministerial report in order to get full background, approach and general conclusions. 1.4 Organisation of Report The remainder of this Report is structured as follows:

10 Assessment Report for Ministry of Health and Social Welfare 4 Chapter Two presents Ministerial Profile which comprises Role and Functions of Ministry of Health and Social Welfare; Status of D by D Prior to Assessment and a brief description and analysis of Human Resources Management in Ministry. Chapter Three provides Specific Approach and Methodology adopted in Assessment. Chapter Four contains actual assessment and findings on Ministry s D by D. It also presents some General Observations on Assessment. Chapter Five contains Conclusions and Recommendations arising from analysis. The Recommendations are presented in form of matrices which summarise general information obtained from Medium Term Expenditure Framework and Memorandum of Estimates. Annexes: Annex 1 presents list of Participants for Assessment in MoHSW. Annex 2 presents Assessment Matrix Annex 3 presents all activities in MTEF (both for Development and Recurrent ). Annex 4 presents activities from Development to be devolved to LGAs followed by activities from Recurrent to be devolved to LGAs.

11 Assessment Report for Ministry of Health and Social Welfare 5 2 Ministerial Profile 2.1 The Role and Functions of Ministry The Ministry of Health and Social Welfare has primary role of providing health and social services in order to improve and sustain quality of life and social well-being of people of Tanzania. In addition to this role, Ministry is supposed to ensure that all stakeholders in Health Sector are coordinated and assisted in securing equitable health services to people. It is also obliged to make concerted efforts to improve human resource capacity at all levels in terms of quantity, quality and skill mix. The Ministry is responsible for executing following core functions;- (i) Policy formulation, regulation, control, quality assurance, monitoring and auditing; (ii) Resource mobilisation and allocation, coordination and intersectoral linkages; (iii) Management support to level three hospitals including national, referral and special hospitals; (iv) Public Health related interventions; (v) Health and social welfare research; (vi) Management of Executive Agencies; (vii) Supervision of preventive and curative health services delivery; (viii) Training key professional health cadres and monitoring quality of training offered by private institutions; 2.2 Status of D by D Prior to Assessment The Ministry of Health and Social Welfare is one of pioneers of D by D internalisation. The Ministry started to devolve many of non core health services to LGAs as early as 1997, well before launching of Local Government Reform in This happened because Sector had experienced problems with centrally planned health care management introduced during Arusha Declaration era. The centrally planned and managed health care services proved unresponsive and inefficient. A large and extensive health care network had been established immediately after independence in 1961 and cas-

12 Assessment Report for Ministry of Health and Social Welfare 6 caded in post Arusha Declaration era to a point where each village had a dispensary, a school and pumped water. This was a substantial infrastructure development within health sector, but as provision and management of health services were centralised, it became difficult to maintain and sustain health infrastructure. The erosion of health care service delivery resulting from this centralisation made early attempts to revive system unsuccessful. The demand for more, new rapies, technologies and health interventions necessitated a new approach to way of doing business in sector. Getting drugs and or essential health amenities into dispensaries and into hands of people who needed m required health systems that had information, communication, transportation logistics, diagnostic, and human resource capacities sufficient to move drugs and or health care amenities to right places, in right numbers, at right times, to right people and with counselling and follow-up efficiently and effectively. This decentralisation by devolution modality was implemented by Ministry through a project known as Tanzania Essential Health Interventions Project (TEHIP) conceived in October, 1993 mainly to develop and test a set of simple, user friendly tools to enable local level health planners to plan on basis of local needs. In 1997 District Health Management Teams (DHMTs) were established to furr objectives of TEHIP. These teams have been instrumental in transformation from centralised service delivery approach to a decentralised participatory approach. Hence, cornerstone of Ministry s strategy for improved service delivery was devolution to local authorities of health care delivery and management responsibilities. After year 2000 furr devolution initiative in health sector took place with establishment of hospital boards to manage health service delivery in ir areas of jurisdiction. From FY 2005/06 grants were also disbursed directly to LGAs from Treasury. 2.3 Human Resources Management The Ministry of Health and Social Welfare has an establishment of 4,154 posts as per approved personal emoluments estimates for FY. Out of approved establishment, re is an actual strength of 3,864 employees, leaving a deficit of 290 employees. The above statistics are for Ministry s Headquarters, Referral Hospitals and Institutions under Ministry s Structure. The optimum size of Health Sectors staff requirement in LGAs is 46,868. The actual strength for LGAs establishment is only 15,060 leaving a deficit of 31,808. There is refore a huge deficit (about 67.9%) of human in Health Sector. This deficit will take more than ten years to be filled if current training output of 2,748 annually is maintained. Notwithstanding chronic manpower shortage in Health Sector, remarkable progress has been achieved in building capacities of LGAs to cope up with demand for health care services. Investment in human has surged over a number of years and tailor-made courses have been designed and implemented to increase productivity of workforce.

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14 Assessment Report for Ministry of Health and Social Welfare 8 3 Specific Approach and Methodology This chapter presents specific approach, documents used and detailed methodology. For more information on overall approach reader is referred to Main Report. 3.1 Specific Approach The sub-group which was designated to scrutinize MoHSW s adopted following approach: (a) (b) Held discussions with Acting Permanent Secretary and appraised on D by D assessment Assignment in Ministry. Reviewed various documents related to Ministry s budgetary allocation to different activities as outlined in MTEF, Health Sector Strategic Plan, Memorandum for Ministry s Estimates, Development Book, Volume IV, Recurrent Book, Volume II and Approved Personal Emoluments Schedules. The details of documents are presented in following section. 3.2 Documents Examination of MoHSW budgetary allocation depended on availability of key ministerial documents. For actual assessment of Ministry s budget for FY following documents were used by Team to undertake assessment: (a) The Health Medium Term Expenditure Framework this was one of key documents used in assessment as it proved to have more accurate, reliable and verifiable data for FY 2008/09. (b) The Medium Term Strategic Plan. (c) The Functions and Organisation Structure. (d) Memorandum of Estimates. (e) Development Book, Volume IV. (f) Recurrent Book, Volume II. (g) Approved Establishment.

15 Assessment Report for Ministry of Health and Social Welfare 9 In order to ensure that Task Team members were D by D knowledge-based, each participant was provided with a copy of Local Government Reform Policy and D by D Strategy and Road Map Embedding Decentralisation by Devolution Across Government as background information documents. 3.3 Detailed Methodology The MTEF activities and ir respective budgets were examined. The Development and Recurrent s were scrutinized. The detailed methodology used in assessment is as below: (a) Development : (i) Extraction of Statistics from relevant Sub-Votes, Project Numbers and Performance Codes (Segment 2) were noted using matrix. (ii) The Activity Name was recorded and noted. (iii) Details extracted above were entered into matrix for assessing D by D. Sufficient details were included in Column 2 (Service and Activity Name) in matrix to provide meaningful inference (deduction) of D by D implementation. (iv) Validity of data extracted was confirmed by a verification of same from Ministry of Finance. The Ministry of Finance was represented in Team. (v) Rapporteur completed filling matrix after due confirmation and verification of information by Team. (b) Recurrent The Recurrent was likewise examined using MTEF which has one matrix listing all recurrent activities and ir corresponding budget line items as follows: (i) The MTEF Segment Code was included in Matrix in Column 1. The Segment Code is a six digits combination of letters and numbers. (ii) The GFS Codes were rarely used in assessment as y represented minute statistical details which were not relevant to assessment. (iii) The Service or Activity Name was inbuilt in Column 2. (iv) The Columns in Matrix Format were filled with relevant information which was related to D by D in each Activity. (v) The Rapporteur completed Matrix after due verification by Team to ensure validity of data and refore right inference from data entered into matrix.

16 Assessment Report for Ministry of Health and Social Welfare 10 (vi) Resulting from above procedure, matrices were produced which were instrumental in determination of what Activities and ir corresponding should be subjected to being devolved to LGAs in fulfilment of D by D objectives. This next chapter contains outputs of assessment undertaken by Team at Ministry s Headquarters in Dar es Salaam. The analysis identified activities and programmes in budget which were not within core functions but rar of an implementation nature which should be devolved to LGA. However, before actual assessment findings are presented, some broad devolution criteria derived from D by D policy and principles which provided overall framework from assessment are presented.

17 Assessment Report for Ministry of Health and Social Welfare 11 4 Assessment and Findings 4.1 Assessment and Analysis Criteria Based on LGR Policy and principles of D by D it can be stated that in a devolved system of governance central institutions should remain with responsibilities of policy formulation, provision of a regulatory framework, standards setting, inspections, monitoring and auditing. The Local Governments have been assigned by law major responsibility for service delivery in an efficient and effective manner. The Central Government has a responsibility of creating an enabling environment for LGAs to carry out ir mandated responsibilities. This includes building necessary capacity of LGAs for m to manage ir new responsibilities. The principle of subsidiarity should be complied with, i.e. that control and management of services are best attained at level where se are delivered and consumed. Furr, it is of critical importance that in process of devolving functions to lower levels adequate are provided to LGAs in accordance with principle that (both financial, human and material) follow functions. The following broad criteria were applied in all ministries including MoHSW in determining which responsibilities and ir attendant should be devolved to LGAs: o Implementation of required interventions for purpose of executing national policies and strategies. o Activities that are planned and implemented by communities at lower level LGAs, o Activities that require community contributions in terms of finance or in-kind e.g. labour, building materials and etc. o Capacity building related to technical and professional development with large capital outlays. Short term training within respective LGAs will ideally be devolved to enhance D- by D. o Routine data collection, monitoring and reporting (although monitoring is also a responsibility of CG, LGAs should also have adequate for monitoring).

18 Assessment Report for Ministry of Health and Social Welfare Assessment and Analysis Matrices Using above broad criteria developed activities in MoHSW s MTEF were identified, assessed and weighted to determine ir D by D value and relevance. The details of assessment and analysis are included in Annexes 3 and 4. Annex 3 comprises systematic assessment of MTEF activities. Annex 4 comprises activities which following assessment are to be devolved to LGAs. The arguments are provided in assessment matrix last column. The activities from development budget are listed first, followed by activities from recurrent budget. All or activities than ones singled out in Annex 4 are to remain with Ministry. 4.3 Assessment Findings The analysis of MoHSW budgetary allocation indicates that Ministry has strived to devolve activities of implementation nature and ir corresponding to LGAs. This initiative has proved that it is possible to begin to improve health services delivery significantly when services are divested downstream to LGAs and communities even with marginal funding while working for more substantial increases in budgets provided that are allocated more rationally. The success of health sector reform was predicated upon Tanzania Essential Health Interventions Project which sought to be a uniquely collaborative venture with LGAs. The situation as it obtains now it that Local Government Authorities are in control of District Health designated as Account No.6 except rationalisation and control of distribution of drugs which is done through Medical Stores Department (MSD) and or pharmaceutical supplies. LGAs are in addition responsible for rehabilitation of health facilities in ir jurisdiction. The LGAs can now access Health Basket Grant Funds through Comprehensive Council Health Plans (CCHP) which allows m to undertake rehabilitation works to health facilities as long as such works do not exceed 20% of Basket Funds Grant. In order to sustain this initiative, MoHSW and PMO-RALG have established a Joint Rehabilitation Fund, developed Rehabilitation Guidelines and produced District Health Infrastructure Rehabilitation Strategy to be implemented in all LGAs. Also funds to meet cost of rehabilitation of health infrastructure facilities are generated from user fees. Under cost sharing arrangements in health sector, user fees have been introduced. The user fees are collected by respective District Hospitals and Health Centres. Community contributions are collected, managed and used at LGA and Lower Level LGAs. Anor important aspect of health sector reform is introduction of Community Health Fund to translate government commitment to promote equity, access, participation and a multi-sectoral systemic approach to improving health services in country. MoHSW designated Community Health Fund, prepared guidelines, training manuals and planning for activities. Implementation of Community Health Fund framework was undertaken by LGAs by:

19 Assessment Report for Ministry of Health and Social Welfare 13 (i) Promulgating a by-law to establish CHF in ir respective areas of jurisdiction (ii) Creation of Boards and Committees to manage funds (iii) Disbursing Central Government Grants to beef up CHFs Execution of CHF has progressed in 67 LGAs and rest are at different stages of implementing guidelines on CHF establishment. The health sector reforms have gone a milestone furr in ensuring that a fair system of allocating between Central Government Institutions and local government partners exists. In collaboration with PMO-RALG, MoHSW has designed a formula based allocation with predetermined allocation criteria to devolve health basket funds under SWAP arrangement. The allocation criteria provide following formula to be put into use: (i) 70% allocation based on population factor of LGA (ii) 10% allocation based on burden of disease factor in LGA (iii) 10% allocation based on poverty index factor of LGA (iv) 10% allocation based on geographical size factor of LGA The above positive situation notwithstanding, following lists in a summary form which activities should still be devolved to LGAs: o All preventive activities of Primary Health Care service delivery should be devolved to LGAs. o Procurement of 30% of essential drugs budget (MSD) should be devolved to LGAs in accordance with National Drug List. o Epidemics, emerging and re- emerging diseases like AIDS, TB and Malaria prevention activities will require involvement of both Central Government and LGAs in planning and implementation. o Procurement of medical instruments, reagents, dental equipment, STI drugs and non medical equipment should be devolved to LGAs. o Vehicles for transportation of drugs, vaccines, medical supplies and ambulances should be procured, managed and replaced by LGAs. o Activities involving provision and support to Orphans, Elderly people and or vulnerable groups should be devolved to LGAs. o A few existing institutions under Ministry which provide services and support to elderly and children homes, centers for disabled will continue to be run and managed by centre until adequate capacity is built at LGAs level. o Routine and preventive maintenance of equipment, instruments or infrastructures should be devolved to LGAs.

20 Assessment Report for Ministry of Health and Social Welfare General observations from Assessment The Ministry has gone a long way towards D by D. A key component of Tanzania s health sector reforms was establishment of District Health Management Teams (DHMTs) in each Council. Local health services had previously been planned and executed centrally by administrators of Ministry s Headquarters, but learning from experience, Ministry became a pioneer in internalising D by D subsidiarity principle. It was convinced that devolving planning and management responsibilities to local teams, composed of members with complementary skills and multiple areas of expertise, would lead to policies and administrative practices that better suited local needs and conditions. s, for example, could be allocated to DHMTs on basis of prevailing local mortality rates rar than on basis of incrementalism or in step with national health priorities. Notwithstanding above enumerated achievements from health sector s commitment to decentralisation by devolution as part of its package of health care reforms, following issues need to be considered in order for health sector reforms to buttress universal nature of health social services benefit to people: (a) (b) To perform se new functions given to DHMTs, training, retooling measures and systemic support to help DHMTs determine actual local prevalence of diseases, to allocate funds appropriately and to meet national standards of practice, reporting and accountability are imperative. Review and harmonize some of sector laws with centralist tendencies and orientation. These laws have been identified and listed in Task Force on Legal Harmonisation Report and y include: (i) Tanzania Food, Drugs and Cosmetics Act, No. 2 of 2003 highly centralised structure of administrative and legal frameworks (ii) (iii) (iv) (v) The Pharmaceutical and Poisons Act, No.9 of 1978 which does not recognize role of LGAs in administration of its provisions Day Care Centres Act, No.17 of 1981 (Cap.180) No LGAs involvement Infectious Diseases Act, No.3 of 1920 (Cap.96) No LGAs involvement in its administration Traditional and Alternative Medicines Act, No.23 of 2002 No LGAs involvement

21 Assessment Report for Ministry of Health and Social Welfare 15 5 Conclusion and Recommendations 5.1 Conclusion In conclusion, it is arguable that higher quality and greater utilization of health services, and better population health are logical products of increased technical efficiency of health system (through stronger planning, management and administration at LGAs and Lower Level LGAs, increased allocative efficiency of health system and new incremental funding with decentralized control. 5.2 Specific recommendations Based on above assessment and analysis of budgetary allocation in MoHSW FY, this Report provides Specific Recommendations of Activities or Programmes to be devolved to LGAs in with D by D principle of subsidiarity which holds that services are best performed where y are provided and consumed. The matrices provided below contain Activities in both Development and Recurrent s which should be devolved to LGAs alongside ir corresponding implementation. These outputs are to feed into 2007/08 Guidelines and Guidelines for Local Government Authorities. Development Activities to be Devolved to LGAs S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SUB-VOTE SERVICE OR ACTIVITY NAME 1003: POLICY AND PLANNING G01D01 To rationalize primary health care facilities in rural areas BUDGET AMOUNT L. 260,005,000

22 Assessment Report for Ministry of Health and Social Welfare 16 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME C01C14 To build Capacity to CHMT, RHMT Manyara Region on Operational Research methods and methodologies. Training on proposal development, Data collection and Training on Data Analysis and Report writing. SUB-VOTE 2001: HOSPITAL SERVICES - Lupaso Health centre : - G01D07 To complete upgrading of Lupaso Health centre SUB-VOTE 3001: PREVENTIVE SERVICES G01D06 To procure 2 vehicles for new District Councils H04S04 To support to 121 Councils in Advocating and updating lower level facilities (Health Centre & Dispensaries) on HSR and delivery of Quality services every year up to H04S29 To train RHM/CHMT on PLAN REP - DHA roll out and follow up by ZTCs H04S31 To conduct 23 training sessions on IMC to RHMT/CHMTs in 17 regioncoordinated by ZTCs including follow up H04S33 To support scale up of intervention IMCI BUDGET AMOUNT F. 57,962,000 F. 358,610,000 F. 144,000,000 F. 23,400,000 F. 381,068,920 F. 76,235,000 F.883,350,000 SUB VOTE 4002: SOCIAL WELFARE G01D01 To provide support to orphans and or vulnerable groups L. 303,200,000 Total 2,487,830,920

23 Assessment Report for Ministry of Health and Social Welfare 17 Recurrent Activities to be Devolved to LGAs S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME : POLICY AND PLANNING BUDGET AMOUNT 2 C01C05 To print and distribute MTUHA data collection tools 90,000,000 3 C01C11 To build capacity for Mtwara and Lindi CHMT, RHMT on Operational Research methodology, data garing, 72,419,000 analysis, report writing and dissemination. Training on proposal development, Data collection and Training on Data Analysis and Report writing. 2001: HOSPITAL SERVICES 1 A01S01 To provide Training on implementation of Quality Systems to support 31,700,000 HIV/AIDS care and treatment for 160 Clinical Diagnostic staff in primary health care each year in 60 centres and 121 councils/districts facilities by June A02S02 To conduct training of assessors of home based care of PLWHAS by June 9,829, A02S03 To conduct situational analysis of home based care of PLWHAS 9,349,000 4 C01S01 To provide health supplies (medicines, 11,372,216,340 diagnostic, dental and medical supplies) to health facilities at all levels by June : PREVENTIVE HEALTH SERVICES 1 A01S05 To provide PMTCT training to 10 health centres in each 14 districts G. 7,000,000 2 A02S30 To conduct orientation workshop on Accreditation of VCT services in 21 Regions 3 A02S36 To conduct 5 sessions of CHBC training for 30 participants per District for 5 Districts for 21 days. G. 13,392,000 G. 94,097,500

24 Assessment Report for Ministry of Health and Social Welfare 18 PROJECT CODE/ ACTIVITY NO. S/N /SEGMENT 2 SERVICE OR ACTIVITY NAME BUDGET PERFOR-MANCE AMOUNT CODE 4 A04S01 To procure STI drugs G. 72,491,600 TFNC Tanzania Food and Nutrition Centre 5 B01S02 To provide Technical support to Councils in planning and implementation of nutrition activities by June B01S03 To provide technical support on Community Based Management Information System (CBMIS) and O and OD planning process to 10 Councils by June B01S11 To establish teams and provide technical support to 5 councils to incorporate CBNR in ir comprehensive council health plans by year 2007 IMCI Integrated Management of Childhood Illnesses 8 B02S09 To conduct District Advocacy for Community IM CI and training for 480 community IMCI District TOTs in 8 councils for 6 days by 2007 (2per quarter) TFNC Tanzania Food and Nutrition centre 9 B03S08 To produce, process, preserve and consume micronutrient rich foods in Singida rural, Iramba and Manyoni by June 2009 EPI Expanded Programme on Immunization 10 B04S02 To support and facilitate repair of solar refrigerators in 121`councils by 2009 G 39,640,000 G. 15,550,000 G. 29,350,000 G. 44,988,200 G. 8,150,000 G. 33,600, B04S13 To install LP gas and conduct maintenance training to CCOs & RCHCOs in recently installed seven regions RCHS Reproductive and Child Health Services 12 B05S07 To print and distribute IEC/BCC messages and materials in all districts that will be used by women, men and adolescent on Focused Antenatal, birth pre- G.48, 953,300 G. 350, 000,000

25 Assessment Report for Ministry of Health and Social Welfare 19 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME paredness, pregnancy danger signs BUDGET AMOUNT 13 B05S11 To facilitate 50 peer education Paraprofessional counsellors on ASRH (five districts) three districts of Kilimanjaro. (2) in each village (man and woman) selected and youth service course 25 pax. 14 B06S01 To conduct 2 courses of 6 days each to strengn focused ANC in 2 regions (40 pax) annually 15 B06S02 To update skills of 70 service providers at hospitals, health centres and dispensaries in life saving skills in 5 region s 14 participants 16 B06S7 To print and distribute maternal and prenatal death review forms, RCH card no. 1, 4& 5 for health facilities 17 B06S8 To train 50service providers in prevention and Management of FGM in districts with high prevalence of FGM annually 18 B06S9 To train 24 service providers on PAC annually NSHP B09S01 School Health Services To conduct 10 days advocacy on Health Screening, School Feeding, First Aid, School De-worming and Environmental Sanitation in schools to 40 Local Government Authorities annually by June, B09S02 To train 80 School health coordinator's from 27 Councils and 4 Regions for 11 days on School De-worming, Health Screening and First Aid Services to pupils/students in schools annually by June, G.28, 928,000 G.23, 056,000 G.91, 964,000 G. 232, 382,000 G.32, 800,000 G.33, 225,000 23,000,400 G. 33,184, B09S03 To train 80 Regional and District School Health coordinator's for 12 days on G. 45,355,100

26 Assessment Report for Ministry of Health and Social Welfare 20 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME Adolescent Reproductive Health (ARH) issues annually by June, BUDGET AMOUNT DHS District Health Services 22 C01S02 To facilitate and support availability of transport to Councils for supervision and distribution of health commodities/supplies such as vaccines, contraceptives, drugs, supplies annually by June C04S01 To facilitate and support training/ orientation of Councillors and Council Health Management teams and RHMTs on establishment of CHSBs, CHF and training of CHSB members on ir roles and responsibilities in supporting delivery of quality health services at community. G. 580,000,000 G. 166, 626,000 Malaria Malaria control 24 E01S13 To conduct 2days advocacy meetings to council leaders on Malaria Communication strategy and Community Based malaria Control Initiative by June 2007 G. 78,480,000 EPID Epidemiology and Disease control 25 E06S01 To train 60 Districts out of 121 districts on how to analyze, interpret and use of IDSR data (use of district analysis book, etc) by E06S010 To facilitate IDSR training including diseases outbreak preparedness including Avian Influenza to all CHMTs in 4 out of 15 remaining regions (Mtwara, Lindi, Mwanza and Kagera) by Vector Vector Borne Diseases control 27 E08S02 To train 30 clinical Officers and Laboratory Technologist in Hanang, Mbulu, Mvomero,Karatu, Monduli,Iringa, Muleba, Maswa, Bukombe and Dodoma G.20, 280,000 G.40, 355,000 G.14,170,000

27 Assessment Report for Ministry of Health and Social Welfare 21 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME on diagnosis and treatment of Tick Borne Relapsing Fevers BUDGET AMOUNT 28 E08S03 To train 20 CHMT in members in Hai, Muheza, Mwanga, Kinondoni, Rufiji,Lindi Urban, Singida rural, Iringa Urban, Muleba, Shinyanga Urban on Vector Borne Database 29 E08S04 To train Health Officers in 12 district councils on neglected Vector Borne Disease and ir control. OCCP Occupational Health services 30 E10S03 To orientate health personnel on improved skills in pollution prevention and OHS at workplace for integration of OH with PHC by June E11S16 To train Arumeru Health workers on health effects due to chemical and pesticides by Dec 06 Eye Eye care services 32 E13S01 To conduct second round Mass Drug Distribution of Zithromax in 26 Districts by July 2006 Environment Environmental Health and Sanitation G.14, 125,000 G. 16,450,000 G. 56,250,000 G. 53,875,000 G. 130,000, E16S10 To facilitate and support Healthy Village Development Programs in 21 regions by 2008 through participatory approaches. HES Health Education and Promotion Services 34 E21S02 To develop training package and conduct technical capacity building for 20 CHMTs on communication planning and procedures for effective communication practice. G. 124,940,000 G. 56,220,000

28 Assessment Report for Ministry of Health and Social Welfare 22 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME 4001: TANZANIA FOOD AND DRUG AUTHORITY 1 C02S02 To conduct ADDO advocacy workshops for Mtwara regional authorities, RMT, District secretariats, CHMT, division secretariats, ward inspectors and DLDB owners (900 px) 2 C02S03 To conduct ADDO advocacy workshops for RUKWA regional authorities, RMT, District secretariats, CHMT, division secretariats, ward inspectors and DLDB owners (1000 pax) 3 C02S05 To conduct 2-days training of Regional and Districts Drug Technical Committee members (12 RDTC and 55 DDTCs) on inspection and supervision of DLDMs Rukwa and Mtwara Regions 4 C02S06 To conduct interview and selection of applicants for dispensers' training in Rukwa and Mtwara Regions 5 C02S07 To train 800 ADDO drug Dispensers in Mtwara and Rukwa regions 6 CO2S8 To conduct training on ADDO regulations to 230 DLDM owners in Mtwara and Rukwa regions 7 C0209 To conduct 2 days training of 1000 ward Inspectors in roll out regions 8 C02C10 To conduct final inspection of existing DLDB and new premises before accreditation 9 C02C11 To conduct inspection on DLDM by DDTC, ward inspectors and audit inspection of ADDOs 10 D01S9 To conduct training on reporting and management of FBD and ADR and carryout supportive supervision in 10 districts BUDGET AMOUNT 84,945,000 95,745,000 21,160,000 12,070,000 G. 342,531,800 G. 24,499,800 G. 121,200,000 G. 28,600,000 G. 100,879,200 G. 41,160,000

29 Assessment Report for Ministry of Health and Social Welfare 23 S/N PROJECT CODE/ ACTIVITY NO. /SEGMENT 2 PERFOR-MANCE CODE SERVICE OR ACTIVITY NAME 11 DO1S32 To conduct workshop to District/ Municipal/ City executive Director on improvement of slaughter facilities sanitation in Eastern zone and harmonization meeting on operation of pharmaceutical business with or government institutions 12 D01S33 To conduct review meeting to food and drugs inspectors from Ward to Regional level, Counsellors and Stakeholders on requirements of TFDC Act, 2003 in lake zone 4002: SOCIAL WELFARE 1 I02S02 To procure and rehabilitate disabled appliances 2 I07C01 Identify number of OVC in 15 Regions by year 2008/09 3 I08S01 To provide 300 mors with Presidential bounty for triplets children born joined by year 2008/09 4 I0805 To provide subvention to civil society providing services to elderly PWDs and most vulnerable children by year 2008/09 BUDGET AMOUNT G. 11,200,000 G. 17,435,000 50,000,000 29,150,000 12,750,000 G.70, 000,000 5 I13S03 To under take data collection on elderly 17,400,000 and people with disabilities by 2008/2009. Grand Total 14,166,423, General Recommendations The assessment and analysis have identified issues which must be addressed if health intervention systems are to play ir role effectively as instruments for improving health care services in a decentralized environment. It is in context of this imperative that following general recommendations are presented below: (i) Expedite process of harmonizing health sector laws listed in Para 4.3(b) above

30 Assessment Report for Ministry of Health and Social Welfare 24 (ii) MoHSW in collaboration with PMO-RALG should prepare a health sector capacity building programmes to support LGAs to secure requisite human management capacity for District Health Management Teams and Hospital Boards in LGAs and lower level LGAs.

31 Assessment Report for Ministry of Health and Social Welfare 1 Annex 1 List of Participants

32 Members of Task Force Team of D by D Strategy implementation The Task Team for MoHSW is marked with * ANNEX 1 S/N NAME DESIGNATION MINISTRY/ ORGANISATION MOBILE 1 Mr. A.L.R. Kabagire PM-LGRP PMO-RALG Mr. S.K. Mbwillo OMLA PMO-RALG Mr. Charles Cintika OM[PMORALG] PMO-RALG Mr. Edson J. Luvanda AG.ADHC PMO-RALG * Mr. Obadia Mtei ADSD PMO-RALG Mrs. Theodora Mollel ADCA PMO-RALG Mr. G.J. Kisaka SEM WATER Mr. Emmanuel Daniel ECONOMIST WATER * Mrs. Anna Nswilla DHS AFYA * Dr. Faustin Njau H,HSRS AFYA Mrs. E.C. Kizwalo KILIMO Mr. A.A. Kajugusi KILIMO Mr. Jumanne A. Sagini PEDP COORDINATOR ELIMU Mr. Gwakahuzu PRINCIPAL ECONOMIST ELIMU Mr. Mantoga SENIOR ECONOMIST MIUNDOMBINU Mr. Fintan Kiwoloko ADD/RR MIUNDOMBINU * Mr. A. Adrian SFMO FEDHA Ms. Mie Baek LEAD CONSULTANT COWI Mr. D.M.S. Mmari LEAD FACILITATOR JanD CONSULTANTS * Mr. Igogo FACILITATOR * Mr. W.N. Mogoile FACILITATOR Mr. Joel Shimba FACILITATOR Mr. M.D. Mugyabuso FACILITATOR Mr. S.Y Kaguo FACILITATOR

33 Assessment Report for Ministry of Health and Social Welfare 2 Annex 2 Assessment Matrix

34 GFS Code or Project Code and activity ANNEX 2 resource allocation for and management of Central and Sector Ministries service delivery activities in light of Government s policy of Decentralisation by Devolution Vote: Sub-Vote: Service or activity Group / Beneficiar y Service or activity 1 budget, amount and 2 budget? 3 is responsibl e for activity? 4 is (a) responsible (column 7)? a) b) a) b) a) b) What or are used? 5 control m? Assessment of D-by-D for columns 6, 7, 8 & 9. Indicate, not compliant or or Based on column 10, suggest comply with D-by-D for non compliant columns. Transfer to (b) Sub-LGA level (c) Regional level (d) Or Categories: 1. Policy, planning and development of strategic documents, 2 Delivery of public goods and service, capacity building, i.e. implementation 3. Quality Assurance/control, standard setting and regulation, inspections and monitoring. Classification: For Recurrent budget use PE (Personal Emoluments) or OC (Or Charges). For development budget use DB (Development ). Indicate amount in Tshs in millions 000,000. CG (Central Government), LGAs (Local Government Authorities), Ors (specify who). CG (Central Government), LGAs (Local Government Authorities), Ors (specify who). This refers to significant or. List main categories of, e.g. buildings, equipment, vehicles etc.

35 Assessment Report for Ministry of Health and Social Welfare 3 Annex 3 MTEF activities