The provision of health services in Kinondoni Municipality is hinged on existing public and private institutions working either together or separately under the existing national health policy. In the context of PPP, provisions of health services are highly determined by existing institutional arrangements binding both partners. Implementation of PPP depends upon modification and development of supportive legislation, clear governance structures and sustainable funding mechanisms. In order to understand the provision of health services under PPP, this study investigated the prevailing institutional environment as presented in the next sub-sections.
Public and private health facilities in Kinondoni Municipality
In Kinondoni Municipality, findings from the Comprehensive Council Health Plan (CCHP) of 2016, reveals that the district has more private health facilities than public. According to availed data from the CCHP, the Municipal Council has 24 hospitals, 16 health centres and 158 dispensaries. Of all the existing health facilities, private facilities account for 78 per cent, whereas, public facilities make up to 22 per cent. Further analysis shows that the Municipality has 22 hospitals, 15 health facilities and 118 dispensaries, which are privately owned, while 2 hospitals, 1 health centre and 40 dispensaries are publicas shown in Figure 1.
Figure 1: Distribution of Public and Private Health Facilities in the Kinondoni Municipality
Source: Kinondoni Municipal Comprehensive Council Health Plan, 2
The existence of a number of private health facilities does not contravene the Tanzania National Health Policy of 2007 and the Public Health Policy Act of 2010 which state that, where there is a private health facility, the government should not construct another health facility of the same nature. Figure 1 reveals that the private sector responded positively to the call to participate in health service provision in Kinondoni. This response implies that the private sector will continue to dominate the district in terms of the number of health facilities in the foreseeable future. Under PPP, the government put in place appropriate infrastructure, as well as giving some autonomy to these private facilities to run important duties that were previously performed predominantly by the public health facilities. These include provision ofclinical services to pregnant mothers, children under five years’ vaccination and the inclusion of health insurance.
Institutional arrangements for the provision of health service under PPP
Documents reviewed indicate that provision of health services under PPP in Tanzania and Kinondoni Municipality in particular, follows the established institutional arrangements that guide its implementation. The discussion with health officials at the district revealed that the existing interface between the public and private actors that are bound by the established institutional framework influences directly and indirectly the synergy of two partners (public and private) when providing services. Despite the contract, participants from the private health facilities lamented that there are inequalities regarding power in decision making and implementation of activities under PPP. This has hindered smooth implementation of partnerships. Kimenyi and Meagher, Amarakoon as well as World Health Organisation (WHO) also contend that health systems under PPP in many developing countries are plagued by poor design of institutional framework, complex relationships among partners and weaknesses in public health policies [33, 34, 35]. Therefore, Tanzania just like any other developing country faces challenges emanating from inadequacies of institutional arrangements.
Obstacles to health services delivery under PPP
Provision of health servicesunder PPP in Tanzania has faced significant challenges. These have resulted from existing interface of institutional arrangements for implementation of PPP activities that vary from the state, community or partners. In this study, several challenges were revealed ranging from policy compliance to inadequate resources as explained in the following sub-sections.
The findings reveal that there are inadequate regulatory mechanisms as well as non-compliance issues. Notably, despite the existence of regulatory framework guiding PPP, the study reveals implementation challenges attributed to inadequacies in guidelines. It was observed that PPP governance structures at local level were lacking and therefore implementation of PPP activities was overseen by the Ministry of Health. Local authorities implementing the PPP arrangements were thus denied the mandate to manage partnerships. This creats bureacratic governance issues where by, sometimes partners at the local levels are answerable to the highest office. Although the Ministry of Health has developed guideline regarding the implementation of PPP, lack of PPP units at Local Government Authorities (LGAs) thwarts this effort. LGAs under this arrangement are contractual authorities with the PPP budget responsible for building the capacity of some personnel at LGAs to implement PPP health service delivery activities. The study reveals that the PPP policy of 2009 was built upon structures already established under the Health Sector Reforms (HSRs). Therefore, the policy may not adequately address the emerging challenges under PPP.
In addition to inadequate guidelines, the study also reveals lack of compliance to the existing policies. Kinondoni Municipality through its District Medical Office (DMO) enforces regulations and standards guiding healthcare provision and ensures adherence to the professional conduct of ethics. To ensure universal access to healthcare service for all, the District has put in place regulations to guide both public and private healthcare providers. This includes treatment of patients in emergency cases regardless of their ability to pay for the services. It was revealed that this policy has not been upheld because in some health facilities, healthcare providers establish their own prices, most of which were too costly for the majority of the vulnerable poor. In an interview with private facility health officials, one of the participants had this to say:
“…this facility was established for income generation and hence offering free services to some emergence complicated cases is costly and yet the government has not been supplementing the resources we have…If the facility has to be sustained, charges must be levied on every client regardless of economic or health status.’’
This portrays that the partners have not been provided with adequate support to enable them to adhere to regulations. The PPP policy guideline of 2013 also indicated that partners need to participate and agree upon all matters related to budget and other plans. Additionally, private health services providers also noted lack of transparency in the guideline for the CCHP especially in the location of funds within the budget framework, hence, hindering effective implementation of the service agreement. Officials from private health facilities also lamented that decisions are drawn by the government (top-down approach). This analysis was also revealed in the study done by Maluka . It was also noted that private health facilities were by-passing hierarchy of referral systems emphasised by the ministry of health as revealed by one of the participants from the private health facility. This was due to the fact that formulated health bodies such as Council for Health Service Board (CHSB), Council Health Management Team (CHMT), District Health Planning Team, and the Hospital Governing Committee had failed to implement the existing regulations and laws to guide health care providers, particularly those from the private sector.
Implementation of the PPP policy, practice and monitoring of activities was paralysed by inadequate resources. The government has not been able to deliver on its promises in the PPP arrangement on key issues especially provision of financial support and requirement. This has affected the provision of health service through the National Health Insurance Fund (NHIF) due to the delay of the government in disbursing funds, as one health facility manager noted during the interview that:
“…it is difficult for us to accept the use of the NHIF card in our health facility because at first, we tried it but always the government delays to make the reimbursement….as you can see our capital is too small to run this business.”
The disbursement of funds is a concern between the local government and ministry of health as well as between the local government and health facilities. The government’s delay to disburse NHIF funds after the private health facilities have provided services affects the mutual trust among partners. Problems of trust exist between local government personnel that handle health-related issues such as the CHMT, CHSB, and Health Facility Governing Committees (HFGC), on the one hand and private health service providers on the other. The underlying problem is exacerbated by the failure of these municipal organs to fully involve the private health providers in the decision making processes. As a result, most of the decisions reached by these bodies were suspiciously considered by the private health facilities. Inadequate resources were also noted as hindering effective information flow in the decentralisation of health service delivery. Therefore, most of the health providers in Kinondoni Municipality did not have the capacity to respond to collaboration needs. Consequently, anticipated positive changes in the provision of health services cannot be attained.
Ineffective monitoring and evaluation of PPP activities
Successful implementation of PPP largely depends on effective monitoring and evaluation of the agreed performance indicators among partners as developed by ministry of health. These include; the degree of collaboration among partners in terms of numbers, contribution of the private and public sector in partnership and client satisfaction rate. These performance indicators were used in monitoring and evaluating the performance of health care providers at the municipal level as revealed by one of the district health officials that:
“Our district has designed monitoring and evaluation mechanisms which demand partneradheherence. We always evaluate how partners follow agreed procedures in all implemented activities in order make informed decisions.”
This revelation indicates that the government has been keen on monitoring to ensure efficiency and effectiveness of health service delivery under PPP. Overall, the central government is mandated to periodically monitor and supervise activities in line with PPP service agreements with partners. In line with decentralisation guidelines, primary health services are supposed to be monitored by LGAs, while regional hospitals are under the supervision of regional authorities [18, 26, 30, 31, 36]. The discussion with government officials revealed that reports from partners were sometimes not submitted, or written and hence, the monitoring team lacked a foundation to assess progress. It was also revealed that enforcement of compliance was ineffective because of limited funds. The district health officials consulted admitted that supervision costs were very high for the municipality and therefore adequate supervision was not conducted.
Insufficient consultation and communication
Private health facilities are mandated to send representative of the respective bodies at Municipal level in Kinondoni. Findings revealed that these representatives are not always consulted. The discussion with Medical Officer in-charge in one private health facility revealed weaknesses in the consultation accountability processes. The process of referral procedures, for instance, from a private facility to government facility is affected by poor consultation among the partners. The same issue was reported by the administrative managers in two private hospitals who noted that although the planning approach is bottom-up and allows for involvement of private sector, they were not consulted enough during the planning process; hence, participation in planning, budgeting and management of resources remained the authority of the Council for Health Management Team (CHMT) at the Municipality instead of being done collaboratively with the private sector. During the interview with one of the Medical Officer in-charge from the private health facility, it was asserted that:
“…when, the Ministry of Health introduced Big Result Now (BRN) plan for implementation for the purpose of attaining the Development vision 2025, Partners were never consulted hence our ideas are not incorporated in this plan….the realisation of the vision is thus doubted’’
This indicates that the public sector, especially at the national and local government level, insufficiently communicates with their partners (private sectors) over the initiatives that are undertaken.
 Big Result Now (BRN) is a delivery methodology focused on delivering specific goals within a stipulated timeline. It applied in the health sector to evaluate health service delivery and outcome.