Policy Meeting Proceedings

POLICY MEETING PROCEEDINGS

17TH NOVEMBER 2014

TABLE OF CONTENTS

ITEMPAGE

1.INTRODUCTION 2

1.1Meeting Objective and process2

1.2Opening remarks 2

2.OPENING STATEMENTS3

2.1Sikika3

2.2Private sector3

2.3Developmentpartners3

3.KEY NOTE ADDRESS –Honorable Minister (MOHSW) 4

4.ISSUES FROM PANEL DISCUSSION 5

4.1Discussion areas5

4.2Main issues covered5

5.POLICY PRIORITIES FOR 2015/16 7

6.HEALTH SECTOR STRATEGIC PLAN IV8

7.CLOSING REMARKS9

ANNEXES

ITEMPAGE

IPolicy meeting time table10

IIPS opening remarks11

IIICSO opening statement14

IVPrivate sector19

VChair DPG-H23

VIHonorable Minister-official opening28

1. INTRODUCTION

1.1Meeting Objective and process

The 15th Joint Annual Health Sector Review (JAHSR)Policy Meeting was held on 17th November 2014 to deliberate on key highlights, recommendations and policy issues arising from the Technical Review Meeting (TRM) held at Kunduchi Beach Hotel-Dar-es-Salaam on 5th and 6th November 2014.

The meeting was officially opened by the Minister for Health and Social Welfare, Honorable Dr. Seif Rashid preceded by opening remarks from the Permanent Secretary (PS)-MOHSW, Dr.DonnanMmbando and opening statements from Civil SocietyOrganisation(CSO), Private sector (PS) and Development Partners’-Health representatives. Highlights from the TRM which were then presented followed by the panel discussion of the highlights, conclusions and recommendations from the TRM. Panel discussion on policy priorities was co-chaired by Minister of MOHSW and Deputy PS ministry of PMO-RALG. Panelists were from DPG-H, WVR, CSO, PS ofMOHSW, and Private sector representatives.

A brief wayforward for Health Sector Strategic Plan IV was presented by the Team Leader. The meeting was officially closed by the Minister of Health and Social Welfare after the closing remarks delivered by the Deputy permanent Secretary –PMO-RALG, Dr. DeoMtasiwa on behalf of the Minister of PMORALG. See annex 1 for time table.

1.2Opening remarks

The PS-MOHSW thanked all participants for availing their time to attend to the Policy meeting. He provided a brief history of the health sector from 1970’s and noted that the health sector moved from hope to crisis periods as a result of oil, debt and economic crisis. 1980’s period was regarded as a lost decade for Health sector progress; however, it was followed by the ‘golden age period’ where health was no longer regarded as a drainer of resources but a key driver for economic development, as demonstrated by a list of Millennium Development Goals. The PS noted the challenge of double burden of chronic care for AIDS and Diabetes which required strategies for action. The PS opening remarks noted the need to pursue synergy for multiple results, maximize the best available resources, and avoid fragmentation by instituting integrated public health approach and measure performance through reliable information. He said policies matter as well as money for better health services and remarked on the role of a better health society for poverty alleviation. The role of strengthening health system could not be over emphasized in all aspects of health sector performance he said. See annex II opening remarks

1. OPENING STATEMENTS

2.1SIKIKA, a member of Policy forum representing a network of 100 CSOs recognized the Governments’ efforts to incorporate the health sector in the “Big Results Now and applauded the inclusion of social accountability as a tool for citizens involvement in improving health services. The statement commended the Government of Tanzania for finalizing and launching Human resource for Health (HRH) strategic plan (2014-19). However, concerns were raised on the slow progress in meeting the Abuja target of 15% (now 10.5%). Noted some of the pitfalls as; late disbursement of funds to health departments and not all resources reach the intended recipients, weakness on delivery of essential medicines and medical supplies. Urged the government to; address factors which foster petty corruption, increase quality and availability of services to promote enrollment of Community Health Fund while empowering the local councils and facilities to manage the collected funds. Improved inter-ministerial coordination between the key ministries for improved planning, budgeting, recruiting and retention of health care workers was also recommended. See annex III for the SIKIKA opening remark.

2.2PRIVATE SECTOR’s opening statement noted that the improved trust between the public and private sectors was a result of Ministry’s commitment to work with the Private Health Sector (PHS). The recent formation of the Tanzania Public Private Forum, by signing of the communiqué between the MOHSW the PMORALG and (PHS) confirmed this move. The Minister of Health and Social Welfare was congratulated for supporting the formation of a fund to provide loans to the Mid Cadre Health care trainees and conducting a joint meeting with all the private health training institutions to search for solutions so as to address the challenges faced by the sector. Delay in revising the directive on Service agreement was a concern; ‘there is no way the private health sector can participate in the BRN with this restriction in place’ he said. He requested the Ministry to have service level agreements for the delivery services and outline each party’s responsibility. Equally the proposed Hospital Categorization, and the expected minimum requirements was hard for PHS to comprehend. On pricing policy he said;‘it was not practical for the ministry to expect same pricing policy for both the public and private health sector. The PHS is undertaking a study on pricing and categorization of health facilities in Tanzania and will share the results. Please see annex IV.

2.3DEVELOPMENT PARTNERS’statement noted that;Maternal, perinatal, and neonatal health indicators showed a very slow progress and Non communicable diseases were now among the top ten causes of morbidity and mortality in health facilities. Child stunting and anaemia were significant public health problems. Other observations were made in 4 BRN areas:

Health systems strengthening: Strengthen the reliability of data systems, and use of data for decision-making capacity particularly at regional, district and lower levels. Emphasized the role of Behavior Change Communication and health promotion as well as a well-functioning community health system and requested a speed up in finalization of community health strategy. On HRH the recommendation was; strong leadership and allocation of adequate resources to address the issues of production, quality of training, placement, retention, and performance management of various cadres of human resource was key.

Accountability: Government’s efforts of accountability were appreciated but a need to pay serious attention to issues of drug leakages were raised in the statement while urging the MOHSW and PMO-RALG to improve audit performance for maintaining the confidence of Development Partners.

Health financing: The representative urged responsible authorities to take immediate action to National Health Insurance Fund (NHIF) contributions of matching fund on Community Health Fund which have not been paid for the last two years. The remarks also noted the issue of Medical Stores Department (MSD) debt and urged to be fully resolved.

HSSP IV development: Informed prioritization based on both burden of disease and high impact cost effective interventions was critical while ensuring that HSSP IV is a realistic and evidence-based plan. The HSSP IV should aim at minimizing inequities and addressing the needs of the most vulnerable people while addressing the issues of quality of services.See annex V DPG-H speech.

1. KEY NOTE ADDRESS –HONORABLE MINISTER(MOHSW)

The Minister said despite the challenges facing the health sector yet a number of achievements have been registered such as; 75%[1] of all health facilities in the country provide service for malaria, IMCI, PMTCT and STI services. 74% of the household population slept under a mosquito net as compared to 56% in the 2004- 5. Currently, 78% of children under age of five year and 80% of pregnant women sleep under a mosquito net. The country was on track to meet the MDG target in 2015 in terms of reduction of Child mortality. Currently the coverage stands at 89%.

He noted that Maternal Mortality rate was still high; whereas the target is to reduce the rate to 265 per 100,000 live births by the end of HSSP III in 2015, it has moved slowly from 578 per 100,000 live births in 2005 to 432/100,000 live births in the current year. Increase in skilled birth attendance moved from 43% (2010) to 52% as reported in the Mid-term review report. Although Tuberculosis continues to account for 7% of the disease burden in the country, yet treatment success rate is 90% well above the World Gold standard of 85%.

As regards to governance; the Council Health Service Boards, Facility Governing Committees, and Regional Referral Hospital Boards have been established to promote good governance with members predominately from the community and service users. Training and use of electronic system to collect important information from health facilities has been conducted and “Telemedicine” system in four referral hospitals is in place. The Minister stressed the adoption of the principles of BRN related to deep prioritization and harmonizing similar interventions. He noted that the HSSP IV shall employ a Comprehensive Social Security Scheme in order to achieve Universal Health Coverage.

He observed that the health sector was a complex system that required all to work in synergy, and capitalize on the investments which the Governments was putting in the sector to make her people safe. Thanked all participants, see annex VI for Minister’s speech.

1. ISSUES FROM PANEL DISCUSSION

4.1Discussion areas

The discussion was centred on the presentation made which was extracted from the Technical review meetings with a focus on Health performance covering; satisfactory immunization coverage, child mortality and stunting, slow maternal mortality and neonatal mortality rates, low facility deliveries and family planning and high HRH gaps which required more efforts in HSS and CBCH revitalization.

Another area of performance was; major causes of deaths which are malaria, pneumonia and anemia children below five years and above five years which were HIV/AIDS, malaria and Tuberculosis, and other non- communicable diseases.

The third area discussed was on key aspects for policy level attention, covering the following;

• Significant inequity in HRH distribution which is adverse in Western regions
• Data issues affecting robustness of information and evidence for decisions
• Limited availability of funds within the sector
• Universal coverage compels establishing one compulsory NHI with safeguards for the poor
• Clients‘ charter is one of the ways to mitigate corruption
• Harmonization, integration, quality and efficiency being key guides

Fourth area was TRM proposed SWAp Policy priorities 2015/16, which covered; BRNwork streams, Community health, Healthcare financing, accountability and social determinants of health

4.2Main issues covered

Health performance

• Nutrition was a multisectoral issue which called for many players involvement. Adequate and safe food supply was important factors in nutrition success.
• It is time now to consider integration of Home based care for those suffering from NCD complications, mainly because of the current challenge of double burden of chronic disease.
• Although the TRM discussion did not go into the detail of emergencies referring to the current Ebola epidemic, yetthe MOHSW needed more time to build core capacities for emergency preparedness response and take it through BRN.
• Child health performance has done well when compared to maternal hence the selected focus on health on emergency Obstetric care (emOC) so as to improve Maternal Health. Although the emphasis is to stress integration of MNCH and continuum of care from Family Planning-Ante Natal Care and post natal care

On the health performancea remark was made on the need to sustain the gains through collaboration otherwise there stands a risk of reverting back.

Health care financing

• As it is now health facilities consider only the main budget into their plans. Revenue collected at the health facilitiesis not reflected in the budget. The move is to encourage the region and health facilities at all levels to focus on their potential in the coming years. Planning, budgeting and forecasting on revenue need to be reflected in the council budget.
• Previously health care service providers used to collect the funds, now there are accountants who collect the funds. Use of IT and insurance experts to improve the claims. Put in place the right system and right person in the right place will improve revenue collection. It was indicated that where management has been rigorous the results have been better.
• It was noted that some health facilities increased their revenue collection without significant costs. It was important for both ministries (PMORALG and MOSHW) to work together on how best the revenue collected at the point of care can be used. The process to review guidelines on how best to use the money at the point of care is going on. Some of these guidelines can be used as a way of testing and learning so that the feedback will improve them.

Public Private Partnership

• Service Agreement should be seen not only as a tool for channeling funds (resource) but also used for service improvement. The SA should cover audit, service coverage accessibility and quality of services. There is a plan for the MOHSW to work together with the private sector on SA.

• On pricing the opinions differed; while the MOHSW did not consider it right to punish the poor by allowing diversity in prices (one place costs are high while others they are low), the private regards self- sustaining as a driving factor in pricing.

• Currently there are many meetings taking place such as HIV/AIDS sector review while the health sector review is also going on. There is a need of coordinating the information on meetings and events so as to minimize overlaps and allow broad participation. One way is to look at a system where MOHSW web site can have all the information on events taking place.

Community health

• The establishment for Community health workers’ (CHW) curriculum is in the final stage. Priority in the recruitment of community health workers should be given to those already practicing. Country wide map out all CHW already practicing before recruitment of new ones.
• Relevant Technical working Groups (TWG) are working together to move the agenda into the final stages.
• BRN accountability will consider the Community Health Workers’ agenda.
• Some of the health facilities are actually managed by the Medical attendants, so there is a need to come up with a training for them, so as to improve their performance above the level of management of Medical Attendant.
• Other areas that need to be considered which support community based health are, like health assistants at the ward level and community nurse who may conduct the outreach services from a nearby health facility.

Health system

• On commodities pilferage; BRN is meant to stop pilferage and BRN will not be limited to only few regions. Health services will be audited and quick action, response and disciplinary action be taken.

• On HRH performance the establishment soon to be approved considers the Technical committee and management committee (CHMT/RHMT). Partners supporting vertical program are advised to work with the whole team and not only vertical staff.
• The team from the PMO-RALG and MOHSW will identify good leaders and support them to scale up the best practices.
• The health sector has a double burden of NCD and a Communicable disease, which calls for a need to prepare, Health Facilities which were not prepared to deal with chronic diseases. Noting that prevention is the corner stone, there is a need to design interventions against the NCD, without forgetting Obesity in Children as a nutritional disorder which is now rising.
• It was noted that the demand for health services is not only dependent on commodities but also to behavior and language of service providers. The improvement approach would be holistic, i.e. focusing on governance, professionalism and performance which will be strengthened in HSSP IV.

1. POLICY PRIORITIES FOR 2015/16

The policy priorities were presented and participants invited to make contribution, the following areas were covered.

Big Results Now(BRN)

BRN objectives will be pursued for the disadvantaged regions; however, the principles of prioritization,equity, efficiency and accountability are encouraged throughout the country.

Community Health

• It was recommended to have a costed health strategy which includes health promotion. Consider appropriate policy support for Community health strategy.
• The practicing and existing CHW country wide should be taken on board by the existing permit. The ZTC may start with CHW training. ZTC are not part of the regional administration but an extended arm of the MOHSW in areas of capacity building, policy implementation follow and monitoring. ZTC interact with the regions to mentor build capacity.
• Community health strategy including community health attendants are to be finalized, curriculum developed and training initiated.

Health Care Financing (HCF)

HCF should be regarded as means and ways for achieving health care universal coverage. The Health Financing Strategy (HFS) to be finalized, approved and the necessary legislation to operationalize the HCF will be developed.

Social Determinants of Health

Focus on prioritized social determinants of health such as; water, sanitation and environment to address including stunting, through enhanced intersectoral collaboration.

The focus should also consider increased social welfare arrangements for the most vulnerable populations.

On ME/Research:

• It was suggested that harmonization should start with planning and have many stakeholders to participate.
• Promote innovations and research for empowering communities and apply evidence-based health care practices for better health outcomes.
• On data and information it was proposed that to include views of service users satisfaction and perception
• ICT for improved service inventory and revenue performance.
• Accountability: Harmonise information systems and improved data quality with increased accessibility by stakeholders for validation of health sector performance.

The general comment: These areas were the priorities for policy, however, the priority areas should be rephrased as policy statement to describe the policy and not as action or strategies.