This section presents empirical findings based on three broad categories. The first sub-section presents the number and nature of health facilities found in Kinondoni municipality, the second sub-section presents the guiding institutional arrangements for PPP operations and the third sub-section presents obstacles existing in the implementation of PPP operations.
Public and Private Health facilities in Kinondoni Municipality
The number of health facilities in the municipality and specifically under the PPP arrangement reveals the quantity and quality of health service provision in the area. The Comprehensive Council Health Plan (CCHP) of 2016 reveals that Kinondoni municipality has more private health facilities than public. Kinondoni Municipality has 24 hospitals, 16 health centres and 158 dispensaries. Findings indicate that 78% are private health facilities, while only 22% are public. 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 public facilities as shown in Figure 1.
The existence of more private health facilities than public ones 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 in Kinondoni municipality responded positively to the national call by government for the private sector to engage in health service provision. Basing on the current statistical trends and policy guidelines as revealed, the private sector may continue to dominate the district in terms of numbers of health facilities and the number of users of health services in these facilities. Findings revealed that existing facilities operating under PPP provide different forms of clinical services that were previously predominantly provided by the public sector. These include provision of clinical services to pregnant mothers, vaccination of children under five years and inclusion of the national health insurance scheme for service users.
Institutional arrangements for provision of health services under PPP
The nature of institutional arrangements under PPP is critical in order to understand implementation flaws. Documents reviewed indicate that provision of health services in Tanzania and Kinondoni municipality in particular, follow the established institutional arrangements that guide PPP implementation. Interviews with health officials from the municipality revealed that the existing public and private actors in health service provision are bound by the established institutional arrangements. Findings established that contracting mechanisms in PPP, marked the establishing of institutional arrangements in Kinondoni municipality. The municipality entered contracts and service agreements with private health care providers guiding the delivery of health services. Key performance indicators were established in aspects of performance management, output measurement and management reporting to enable a robust assessment of contracted performance.
It was revealed that establishing collaboration in decision making and information flow among PPP actors was an important institutional arrangement to facilitate the implementation of PPP processes. Interviews with participants attested that each partner agreed to form an entity body that could ensure that decisions are made in agreement with both parties. Under the public sector, different bodies were established to ensure transparency in decision making and smooth flow information. These included establishment of the Council Health Management Team (CHMT), the District Health Planning Team, the Council Health Service Board (CHSB) and the Health Facility Governing Committees (HFGCs).
Finding from reports indicated that another institutional arrangement was provision of incentives to the private health facilities. This was to encourage result-based services, so as to strengthen partnerships with private entities. It was revealed that the government through the municipality provides, or supports human resource capacity building in private health facilities particularly for-non-profit healthcare facilities. For instance, the municipality provides health workers to MICO Rabininsia Memorial Hospital and Mbweni Mission Hospital for delivery of services such as Maternal and Child Health (MCH) care, vaccinations and provision of care and treatment clinic to Tuberculosis (TB) infected persons and people living with HIV/AIDS. Also, the private health facilities are provided with medicines such as ARVs and medical equipment. The municipality ensures that partners receive the incentives expected in accordance with the district annual budget. Reiterating this, one official explained that:
The municipality allocates ten percent of the budget annually for private health service facilities. In the past, we were allocating these incentives in terms of financial resources only, but recently we have also decided to provide medical equipment, medicines and human resource support.
The official from the MoHCDEC gave more clarification concerning incentives. Private health facilities which comply and meet the set standards in the institutional arrangement are prioritised for supplies of incentives to meet the technical, or financial needs.
Obstacles to health services delivery under PPP
In this study, several challenges that constrain smooth implementation of PPP arrangements in the delivery of health service in Kinondoni municipality were revealed. These are categorised into: regulatory issues, inadequate resources, ineffective monitoring and evaluation of PPP activities as well as insufficient consultation and communication.
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. Notably, the study reveals implementation challenges attributed to inadequacies in the guidelines. It was observed for instance that the PPP governance structures at local level were lacking and therefore implementation of the PPP activities was overseen by the MoHCDEC. This creates bureacratic governance issues where by, sometimes partners at the local level are answerable to the highest office. Local Government Authorities (LGAs) under this arrangement are contractual authorities with a budget and responsibility to build the capacity of personnel to implement PPP health service delivery. However, this has not been effectively implemented as one participant revealed.
“…as local government, we have not been able to train the staff in the health department engaged in PPP activities...that is why in most cases, it is the line ministry officials who are active in the implementation of the PPP activities in the district”
The revelation reflects the bureaucratic governance mechanisms witnessed in the implementation of PPP activities in the district and lack of skilled personnel to oversee PPP arrangements’, which is attributed to policy inadequacies. In addition to inadequate guidelines, the study also reveals lack of compliance to the existing policies and established guidelines. The municipality through the 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 municipality 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, health service providers establish their own prices, most of which were too costly for the majority of the vulnerable poor. In an interview with one official from the private health facility, the following words were echoed:
“…in the first place, this facility was established for income generation and therefore we have standard service charges for specific cases and if the facility has to be sustained, charges must be levied on every client regardless of economic or health status. It is also costly to handle some emergence cases.”
The official further expressed fear that some patients could use this opportunity to seek for free services in the name of emergence. It was also expressed that if the government would supplement the facility with adequate resources, this guideline would be implemented without failure to comply. The PPP policy guideline of 2013 also indicates that partners need to participate and agree upon all matters related to budgets and other plans. Officials from private health facilities lamented that decisions are drawn by the government (top-down approach). Quite often the decision making process has not been participatory. For instance, the private health service providers noted lack of transparency in the guidelines for the CCHP especially in the allocation of funds within the budget framework, hence hindering effective implementation of the service agreement.
It was also noted that private health facilities were by-passing the established hierarchy of referral systems that is emphasised by the MoHCDEC. This was depicted by the tendency of private dispensaries and private health centres referring patients directly to more specialised hospital levels like Mwananyamala Hospital (government), Herbert Kairuki Hospital (private) and Muhimbili National Hospital (government), as revealed by an official from one of the private health facilities:
“…sometimes we do not follow the hierarchy for referral management and we just refer patients to hospitals like Sinza Hospital, Mwananyamala Hospital, or any private hospital where we are sure that the client will be able to receive specialised treatment.”
The official further revealed that they did not offer official letters to clients referred to other healthcare facilities without following the established referral hierarchy. This reveals lack of coordination between healthcare facilities and lack of clear follow-up plans. It also indicates lack of formal managerial meetings between private health facilities on one hand and other established bodies like CHMT, CHSB, HFGCs at the district with the responsibility to oversee smooth implementation of PPP regulations. Far from the regulatory framework being inadequate and ineffective, financial constraints may also act as barriers to effective PPP arrangements.
Lamentably, in the 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 requirements. This has affected provision of health services using the National Health Insurance Fund (NHIF) payments due to the delays in disbursement of funds by the government as one official from the health facility management team revealed:
“…clients are not able to use the NHIF card in our health facility because the government has not yet disbursed funds for this scheme…we are only serving clients who are able to pay.”
This facility in particular was not accepting to treat patients enrolled under the national insurance scheme. However, in other private facilities, it was observed that patients were using the insurance identification cards and were being offered services. When the health officials were probed on this, they mentioned that they treat the patients even when the government has not deposited the funds on the account, because of the realisation that if patients were to be turned away, most people would not be able to access health services at the facility as one official confided:
“…you see…we cannot wait for the government to first put money on the fund account so as to start serving clients under the scheme because normally the government delays to effect disbursement of funds...so in this facility we opt to save lives first as we wait for the money”
Revelations indicate that private facilities hence have to invest in this partnership because if they were relying on government’s support, they would not deliver health services to all. It was revealed that when the government delays to disburse funds, this affects fulfillment of the partnership and may lead to facilities turning away patients under the national insurance scheme. The delay in disbursement of funds is not only a concern between the local government and health facilities, but also between local governments and the MoHCDEC as well. Inadequate resources was 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.
Lack of trust between PPP partners
The problem of trust between implementers of PPP arrangements in Kinondoni municipality was revealed by participants. Whereas private health providers blamed the existing bodies responsible for overseeing the implementation of the PPP activities in the municipality, on the other hand the private health service providers were also blamed for not fulfilling the decisions agreed upon. For instance, private health service providers kept charging high service fees contrary to the service agreement. Furthering this argument, one official from the municipality commented:
“…the goal of private health facilities is to maximise profit and therefore sometimes these facilities do not adhere to service agreements. At times when we make impromptu supervisions, we find the health facilities operating contrary to the agreed upon decisions.”
On the other hand, private health service providers expressed their disappointment for not being equally represented in the decision making bodies at the district. Although private healthcare facilities were involved in some of the decision making processes in the CHSB, CHMT, District Health Planning Team, and the Hospital Governing Committee, it was difficult to have influence and power over the district’s decisions on health interventions. The private healthcare facilities feel overpowered by government bodies and therefore do not trust that the decisions reached may be in their favour. Such revelations from the implementers of PPP in Kinondoni municipality portray challenges posed by lack of trust and its implication for health services delivery.
Ineffective monitoring and evaluation of PPP activities
Successful implementation of PPP largely depends on effective monitoring and evaluation of the agreed performance indicators between partners as developed by the MoHCDEC. These include the degree of collaboration between partners in terms of numbers, contribution to the partnership and client satisfaction rate. These performance indicators were used in monitoring and evaluating the performance of health service providers at the municipal level as revealed by one of the health officials that:
“Our district has designed monitoring and evaluation mechanisms which demand partner adheherence. We always evaluate how partners follow agreed upon procedures in all implemented activities in order to make informed decisions.”
This 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 the decentralisation guidelines, primary health service providers are supposed to be monitored by the LGAs, while regional hospitals are under the supervision of regional authorities. The discussion with government officials revealed that reports from partners were sometimes not submitted, or not written and hence the monitoring team lacked a foundation to assess progress. Showing concern, the official from government lamented:
“…It is always assumed that the government is not serious, but even the private sector is not effective…Imagine, sometimes the private health facilities under PPP do not submit periodic reports but they need financial support...how do they expect the government to take action when there is no evidence to show activities conducted and services provided?”
Monitoring and evaluation of the PPP activities has not been adequately conducted since there is missing information and lack of compliance on the part of private partners. It was also revealed that enforcement of compliance was ineffective because of limited funds. The district health officials consulted admitted that supervision costs are very high for the municipality and therefore adequate supervision is hard to effect.
Insufficient consultation and communication
Private health facilities are mandated to send representatives to the respective bodies namely CHMT, HDPT, CHSB and HFGCs, among others at the district to partake in the implementation of different PPP processes and activities. Findings revealed however that these representatives were not always consulted. The interview with one official from a private health facility revealed weaknesses in the consultation accountability processes. The process of referral procedures for instance from a private facility to a government facility is affected by poor consultation between the partners. Administrative officials from private health facilities noted that the planning approach is bottom-up and allows for involvement of the private sector, however, they are not consulted adequately during the planning process. Hence, participation in planning, budgeting and management of resources remained the authority of the Council for Health Management Team at the district, instead of being done collaboratively with the private sector. During the interview with one official 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 were not incorporated in this plan….the realisation of the vision is thus doubted’’
This revelation depicts lack of consultation with the private sector in the health service provision and yet, such a strategy requires the participation of key stakeholders in the planning process for smooth implementation. The private sector hence feels marginalised in the partnership with the public sector especially at the national and local government level, where insufficient communication flows over initiatives meant to strengthen PPP are undertaken.
The provision of health services under PPP in Tanzania has faced significant challenges accruing from inadequacies in the institutional arrangements for implementation of PPP activities. These may be associated with the public sector, or private sector. The study has also revealed inadequate regulatory mechanisms, as well as non-compliance issues.
 Big Result Now (BRN) is a delivery methodology focused on delivering specific goals within a stipulated timeline. It is applied in the health sector to evaluate health service delivery and outcome.