Opportunities and Challenges of Implementing Service Agreement between the Government and Faith Based Organizations in Ilala Municipality, Dar Es Salaam, Tanzania


 Background

Access to essential health services is an important aspect of development. Due to the population increase and technological advancement, governments could no longer cater for the services needed. One of the solutions was to involve private sector through Public Private Partnerships (PPPs) in provision of the services. In 2007 Tanzania made a generic Service Agreement (SA) to govern PPPs in health sector. However, since its establishment, less is known on opportunities and challenges of implementing SA in the provision of health services in Tanzania. Therefore, the focus of this study was to assess the opportunities and challenges of implementing SA in Tanzania using a case of SA between the Cardinal Rugambwa Mission Hospital (CRMH) and the Ilala Municipality in Dar es Salaam.
Methods

The study employed a case study design using qualitative method of data collection. Data were collected by using in depth interview guide. Purposive sampling was used to select participants. The sample size was based on the principle of saturation level of the information collected. Data were analyzed using a thematic analysis approach.
Results

The opportunities of implementing SA in CRMH, Ilala Municipality include: the existence of guidelines and policies, Patients receive some health Services free of charges, availability of some services at reduced prices, presence of SA review meetings, good coordination, availability of supervision, training and mentorship opportunities, presence of political support, trust of the hospital by suppliers and trust between government and the hospital. The identified challenges in implementing SA include: - partial fulfillment of financial commitment, inadequacy deployment of HRH to CRMH by government, lack of transport for supervision and donor dependence.
Conclusion

There are a number of available opportunities for partnering between the private sector and the government in the delivery of health services. However, for the PPP to achieve its desired objective of improving access to health services particularly to most vulnerable population such as women and children, there is a need for the two parties (private and public) to address the identified challenges such as partial fulfillment of financial commitment and inadequacy deployment of HRH from the government to the private health facilities as per SA.


Background
Access to essential health services is an important aspect of development. 1 Governments around the world have increased the use of Private sector in a new form commonly known as the Public private partnerships (PPPs) in improving services provision and accessibility. [1][2][3] Reasons for this varies ranging from rising expenditures for constructing, maintaining and operating public assets, and de cit of government budgets, opting for seeking innovation through private sector and better risk sharing and management. 1,[3][4][5] The private sector plays an ever-growing and diversi ed role in the delivery of public services around the world. The level of private involvement in its various forms is now vast. 1,[5][6][7] According to the most recent statistics, private non-for-pro t sector is the second biggest provider of health care after public sector in the world. It constitutes an indispensable addition of 40% to the care provided by the public sector, particularly in rural areas. For pro t private health service providers are mainly found in urban areas and while it is on a growing scale still has remains small. 8 The public sector has been the main actor in the development process of most countries in Africa and beyond until the mid-1980s.This was due to monopoly policy of state economy in most countries especially those that embraced centrally planned economic policies, like Tanzania. 8 The introduction of Structural Adjustment Programme in 1980s, which was designed as an economic revival strategy and advocated for private sector involvement and decentralization of powers to local governments, contributed to establishment of PPP in Tanzania. 9 In Tanzania, despite the fact the private sector existed, the government has been the main provider of health services even before Tanzania became independent. This model of service provision was known as 'Tanzanian model' where by religious freedom was maintained. 8,10 The main private health providers were religious organizations, traditional healers and birth attendants. [10][11][12] Following the winds of change in social, political and economic reforms, the role of the public sector in the development process have substantially changed in many countries. Its role now remained mainly that of a facilitator for the private sector-led economic development and growth. The role of the private sector in bringing about sustainable development in most economies has increasingly been recognized and acknowledged. 1,8,13 One proposed approach to improve coverage and quality of health care for all citizens was to enter into contract with private organizations to deliver speci c services that are pre-de ned by health authorities. 1,2,10,14,15 Public Private Partnership in the Health and Social Welfare Sector can take a variety of forms with differing degrees of public and private sector responsibility and risk. They are characterized by the sharing of common objectives, as well as risks and rewards, as de ned in a contract or agreement. [10][11][12][16][17][18][19][20] The private health sector was deemed better to support the government in implementing different projects due to its e ciency, accountability, quality of service and wide coverage nature. 3,12 However, on various occasions there were reported weak collaboration, coordination and cooperation in health services delivery between public and non-government providers including FBOs and private service providers. 15 The Government of Tanzania started to strengthen the collaboration between public, private and civil society by setting a comprehensive policy, legal and institutional frameworks at all levels. 16,17,21 In 2007 the government together with various stakeholders developed a national Service Agreement template, which was designed as contractual tool to facilitate the implementation of public private partnership projects and collaboration. It de nes how PPP projects will be well implemented and governed. 16 The demand for the SA emerged from both the government and the Private sectors. 6 10 SA is a formal contract established between the government and non-state provider that stipulates the roles and responsibilities of all parties involved in the contract, the types of health care services to be provided, how the contract will be nanced, accountability and performance monitoring mechanisms with focus on public health priorities. 10,11,23 The most preferred areas that are included in the SA as public health priorities include the provision of health services for children under ve, pregnant women, elderly and public goods(Immunization, Malaria, HIV/TB). 15 On various occasions it was reported that the implementation of SA is facing several challenges including inadequate ful llment of roles and responsibilities by government and private partners as per SA. For instance, monitoring of the contractual relationship was not properly done and supervisions has remained erratic. 10,11 However, there is no systematic study that that has been conducted to assess the opportunities and challenges of implementing SA in various areas of Tanzania. This study was an attempt to ll this gap using the case of SA implementation between the Rugambwa Mission hospital and the Ilala Municipal council in Dar es Salaam, Tanzania.

Study area
The study was conducted in Cardinal Rugambwa Mission Hospital found in Ilala Municipality; which is one among the ve councils in Dar es Salaam region. The study setting was purposively selected because Ilala is one of the few municipalities in Tanzania where SA is implemented. It is located at business center and o cial places. The Ilala Municipality hosts around 1,220,611 people 24 who spent their night in the council and more than 4,000,000 people during day time (business time). This large population needs health services and other services as well.
The local government cannot provide all services needed on its own hence needs to involve Private sector. Therefore; the Ilala Municipal Council has to enter into SA with Cardinal Rugambwa Mission Hospital to support in the provision of health services. Cardinal Rugambwa mission hospital was selected because it is found in Ukonga ward with population of 80,034 people 24 but there is no nearby public hospital and it takes three (3) hours from Ukonga to the nearest hospital (Amana regional referral hospital).

Study design
A case study approach was employed in this study whereby Service Agreement between the LGA (Ilala Municipal council) and Rugambwa Mission hospital was regarded as a case for this study for exploring in details and get deeper understanding about the implementation of SA. Case study design was found adequate to this study because opportunities and challenges facing the implementation of SA are not linear and some are embedded in social and economic factors. 25 Sample size and sampling procedures Twenty three (23) respondents were involved in this study including 6 District health managers, 2 Council Health Service Board (HSB) members, 5 Hospital Management Team members and 3 health workers from the hospital. On patients' population; we interviewed a total of 7 patients who were interviewed after receiving health services and the information saturation was reached at the 7 th respondent.
All study participants were purposeful selected because they are knowledgeable and experienced people in the implementation of SA. 25 Council Health Service Board members, Hospital Management Team members and District Health managers were purposively selected for Key Informant interview (KII) due to the roles they play in implementation of SA. We also used convenient sampling to select patients who were receiving health services at Rugambwa Mission hospital during data collection days due to ease accessibility. 26 These were obtained after they have received health service.

Data collection methods
In exploring opportunities and challenges of the implementation of SA, we used in-depth interviews with key informants including Council Health Service Board members, Hospital Management Team members, District Health managers and a few patients. Interview guide was developed to guide collection of primary data. The questions included in the interview guides were framed around two themes originating from the study objectives. First was on opportunities of implementing SA and second was on the challenges of implementing SA.

Analysis plan
A thematic analysis approach was used in analyzing the data. The analysis was carried out in three stages as recommended by Virginia Braun and Victoria Clarke 27 :-rst, the line-by-line coding of eld notes and transcripts; second, the in-depth examination and interpretation of the resultant codes and their categorization into descriptive and analytical themes; and third, the development of an overarching theme.

CHARACTERISTICS OF THE RESPONDENTS
The study interviewed 23 Respondents who were categorized into three categories; the rst category include eight (8) district health managers, the second category include eight (8) facility health care workers the last group include seven (7) patients. Table 1provides a summary of the demographic information of three groups who participated in the study.
The majorities (74%) of respondents were female and 83 % of respondents' ages were above 40 years and 17% were below 40 years. The level of education of respondents varied between patients who had mostly primary and secondary education levels while the district Health managers and hospital care workers had college or university education level. The results are presented in two main themes, the rst theme is on the opportunities of implementing SA, which has eight sub themes, namely: presence of policies and guidelines for implementing SA, patients receiving services at reduced cost and some at free cost, presence of supportive supervision and workers involvement in trainings and mentorship, presence of SA review meetings, good PPP coordination, political support, trust of the hospital to suppliers and trust between the parties implementing SA. The second theme is on the challenges of implementing SA which has four sub-themes namely inadequate deployment of Human Resource for Health (HRH) by government to the hospital, inadequate ful llment of government nancial commitment to support the hospital, lack of transport for supervision and donor dependency.

The opportunities of implementing Service Agreement in the hospital
The participants were asked about the opportunities available for implementing SA as a tool to facilitate the public private partnership projects in the provision of health services in Ilala Municipality. Analysis of the ndings generated eight sub-themes about the existing opportunities for implementing SA, namely: the existence of guidelines and policies, patients receive some health services free of charges, availability of some services in reduced prices, availability of supervision, training and mentorship opportunities, presence of good PPP coordination, presence of SA review meetings, existence of political support, trust of the hospital by suppliers and trust between government and the hospital.
Patients receive some health services free of charges Interviewed patients and health workers at the hospital reported that there are number of health services that are currently provided free of charges. These include: weighing of children, assessment of children, provision of health education, vaccination services, Ant malaria (SP) also known as IPT, drugs for deworming, Ferrous and Folic Acid (FEFO), HIV test, opening of Cards and pregnancy assessment. All these services are provided at the Reproductive Child Health (RCH) clinic as one respondent said, "When I came here while I was pregnant, a number of services were provided free. These included: health education, assessments of pregnancy, deworming drugs and many other services" (IDINo.04 female patient).
Patients receive some health services at reduced prices Interviewed patients and health workers at the hospital reported that there are number of health services that are currently provided at the reduced prices. These include: test for hemoglobin and delivery services.
For instance, delivery services are provided at reduced price of Tanzania's' Shilling 50,000/= instead of 100,000/= per one normal delivery. HB is charged at reduced price of 2000 instead of 4000. One of the respondents reported, "During delivery I could not deliver normally so I undergone Hemoglobin check-up for 2000/= and then after that I delivered by cesarean section which costed only 100,000/= and it was cheap compared to other private facilities for the same services I got here" (IDI No.03.Female patient).

Existence of guidelines and policies on SA
The interviewed study participants reported that the implementation of SA is possible because it is enabled and facilitated by national policies and guidelines. For instance, they mentioned that the presence of SA implementation policies and guidelines clearly state all the procedures for implementing SA at council levels. One respondent said, "We are able to implement Service Agreement without any obstacle because it is directed by national guidelines and policies and not from me as Municipal Medical O cer; if it could be my directives, then we could have failed" (KI NO. 15-CHMT).
Moreover the interviewed members of the hospital management team and health workers reported that the partners who implement SA are also obliged to observe government guidelines that provides directives on how various health services including RCH services should be provided: "We have government guideline related to provision of RCH services here and we are obliged to follow it as per SA" (KINo.02HMT).

Health workers involvement in trainings
Training is one way of making sure that services are provided at the required standards. Health care services do undergo changes in line with technological advancement and recommendations from researches. Interviewed members of the hospital management team reported that after starting implementing SA the staff from the hospital are included into trainings and given updates of services provision by the CHMTs. Such trainings aim at ensuring that services are provided by skilled and updated health care workers. This was not the case before service agreement. This was remarked by one of the interviewed HMT members: "We have seen Service Agreement to be bene cial to us because now days as the hospital leaders and workers are included in the trainings and given updates on changes regarding health services provision. This helps to motivate workers and improves the quality of services provided as agreed in the Contract" (KI No. 11HMT).

Supportive supervision and mentorships
Majority of interviewed District Health managers, members of the Hospital Management team and health care workers mentioned supportive supervision as an opportunity of implementing SA. Supportive supervision refers to a friendly and more supportive way of making something to happen in a right way as required where by supervisor and supervisee assumes the same role of teaching and learning from each other. This was also evidenced by researchers from the hospital visitors' book whereby more than 17 Supportive Supervisions were recorded in the past twelve (12)  reported that Supportive supervisions and mentorships give opportunity for improving the quality of services provided. One of the respondents said: "We are conducting supportive supervision quarterly but for us it is integrated supervision and not speci c for SA. Most of the time it includes different departments such as RCH, Quality improvement, Laboratory services, Pharmacy, HIV and checking for HRH. It is very comprehensive which also includes the services agreed in SA" (KI NO. 16 CHMT).

Service Agreement review meetings
Majority of the interviewed respondents reported that SA implementation is also monitored by the SA review meetings which are done once per year between district government o cials and the Hospital management. The review meetings are used as platform for both parties (Local Government Authority and Rugambwa Mission Hospital) to monitor and evaluate the progress of the implementation of SA activities as well as challenges and solutions of implementing SA. It was reported that SA review meetings give parties an opportunity to report the progress as well as challenges of implementing SA. For example, one respondent had this to say: "We call Cardinal Rugambwa Management members for review meetings every year and we also have long review meeting when the contract ends whereby we as government party, we give feedback and informs them on some changes if any in the contract and they also get opportunity to give their opinions" (KI NO. 19-CHMT).

Trust of the hospital to suppliers
The interviewed study participants reported that the Mission hospital is trusted by suppliers of various drugs and other medical supplies because it is owned by the religious organization. Given such trust, the hospital can take equipment, drugs or medical supplies and promise to pay later. Such arrangement contributes to smooth running of the hospital activities including provision of services as agreed in the SA. The ndings show that the hospital is run by religious congregation which put it at advantageous position to be trusted even by suppliers. One of the respondents said, "We are church people and we are trusted outside (suppliers) there even if we have not received Health Basket Fund for that quarter then we just ask them to supply us with commodities worth even over 30 million and we promise them to pay when we get fund from the Council and most of them, say Sister just take it we are sure you will pay us. And when I get money, I pay them on time. This has helped us to provide services as agreed in Service Agreement even if funds have delayed" (KINo.09-HMT).

Trust between parties in SA
The interviewed district health managers reported that they trust the data and reports from the hospital and also the hospital trusts the government through Municipal Council Medical O ce. They claimed that this type of trust is good for having productive partnership as elaborated by one of the respondents below: "Now we trust them and they trust us very much and we trust even the reports they are submitting to us. This is now very strong even they dare to report the bad things happening such as maternal deaths. For instance last year Cardinal Rugambwa Mission Hospital reported two maternal deaths which were not the case before that because we told them that they will not be penalized when maternal deaths happen but when it happens we need to organize a joint meeting to nd out the causes and put measures of ensuring that it does not happen again" (KINO. 18-CHMT).

Presence of good coordination
The interviewed study participants reported that the Municipal Council Medical O ce has appointed a responsible person to coordinate all Private Health facilities in the council and is responsible for all matters related to SA as well as PPP in general. This was mentioned to be an opportunity in implementing SA in the council. One of the respondents expressed the following: "The act of having PPP coordinator is also a factor which has helped us (the municipal council) and Cardinal Rugambwa Mission Hospital to implement well the SA because he acts also as a channel of communication between the council and Cardinal Rugambwa Mission Hospital and other development partners who have interest in SA and PPP in general. If we miss transport for supportive supervision he goes to APFHA and we are given a car to conduct supervision. He actually coordinates well everything related SA in the Council and that is why we are doing well with SA implementation" (KI NO. 18-CHMT).

Existence of Political support
Majority of the interviewed Municipal Health Managers, Council Health Services Board and members of the Hospital Management Team acknowledged that they get full political support in the implementation of SA. This was seen as a major opportunity because politicians such as councilors have an in uential power in making decision regarding any project or activity, which is being implemented at Local Government Authorities level. In this aspect, one respondent had the following remarks: "The councilor of this area of Ukonga was very positive in supporting SA while holding talks with the Local Government o cials for signing this Service Agreement and he has being supporting its implementation and actually he is a member of Hospital governing Board. He is marketing and advocating the availability of our services to the citizens. He always asks about our services and if we face any challenge he is there to support us. For me I think he has remarkable contribution in successfully implementation of SA in Ilala" (KI No 11.HMT).

The challenges facing the implementation of SA in the hospital
The participants were asked about challenges affecting the implementation of SA in Ilala Municipality. Analysis of the ndings generated four sub-themes as described below: inadequate deployment of health workers to the hospital, inadequate ful llment of government nancial support to the hospital, lack of transport facilities and donor dependency.

Inadequate deployment of health workers to the hospital by the government
The interviewed respondents acknowledged that as part of the SA, the government agreed to deploy seven staff including three nurses, two laboratory technicians and two clinicians so as to increase the number of services provided by the hospital as well as improving the quality of services. However, by the time of undertaking this study, the government deployed only three staff including two laboratory technicians and one (1) clinician. When commenting on the deployment of health workers, one respondent said: "We agreed that the government will deploy seven health care workers to the hospital in these three years of implementing SA including two laboratory technicians, three nurses, two clinicians however till now which is the end of third year we have received only one clinician and two laboratory technicians"(KI No.11 HMT).
Inadequate ful llment of the government's nancial commitment to support the hospital According to SA between Ilala Municipal Council and the hospital, it was agreed the government has to send 10% of total Council Health Basket Fund received to CRMH for each quarter. However the exact amount was not agreed due to its uctuation tendency. The interviewed members of the Hospital Management Team reported that delay of funds caused many problems such as lack of smooth continuation of services because sometime the hospital delay in procuring medical supplies, delaying in paying workers' salaries and inadequate funds for administrative costs. One of the respondents said, "The Health Basket Fund from the government is headache in the sense that it is not coming on time and quarterly as agreed but now it sometimes comes at the end of the quarter and sometimes we do not receive at all and when they send it, it comes two installments for two quarters, one for the current quarter and the other one for the previous quarter but they need to be retired immediately before the end of that quarter. Another thing is that we only know that we are supposed to get ten percent of the total Council Health Basket Fund but we do not know the exact amount since we do not know the total amount of basket funds for the council" (KI No.12HMT).

Lack of Transport for conducting supportive supervision
The interviewed study participants reported that the Ilala Municipal Council Medical O ce has a big problem of transportation and this has affected the implementation of SA as the District Health Managers fail to go for supervision to the hospital. The health department has a few vehicles which are not enough to carry out regular supportive supervision to all health facilities including Rugambwa Mission hospital. One of the respondents had the following remarks, "As I have said earlier on we have failed to go for supportive supervision because we have no transport for such visits as you know we have few vehicles and there are many ad hocks (emergencies) in this municipality. All these emergencies need transportation and you cannot control them" (KINO. 18-CHMT).

Donor dependency
The interviewed study participants especially at District level reported that the Municipal Council Medical If such support decreases and many development partners withdraw as it is the case now or ceases to exist, then the implementation of SA will also stop. In support of this nding, one the respondent said, "We understand that these funds are not ours we are just given by donors. We need to use them well but we would like to acknowledge the support given by APHFTA. Without this association maybe we could not have SA in Ilala. They were the rst to convince us and to talk to Ilala Municipal Council on collaborating and signing SA. Till now they are calling us together and providing trainings on SA. If we have challenges related to implementation of SA we feel that APHFTA's o ce is our home" (KI NO. 01.HMT).

Discussion
This paper aimed at understanding the opportunities and challenges for the implementation of Service Agreement between local government authorities and Mission hospital in Ilala Municipality, Dar es Salaam, Tanzania. Understanding the opportunities and challenges for the implementation of Service Agreement is important because it will help the policy makers and parties involved in Public Private Partnership to utilize effectively the identi ed opportunities as well as looking for solutions to address the identi ed challenges and ultimately implement sustainable SA.
From this study ndings, it was found that there a number of available opportunities for the implementation of SA. In one hand, the implementation of SA has created opportunity for vulnerable population such as women and children to access some of the health services free of charge while on the other hand, patients receive services at reduced prices as per SA. The evidence from this study has shown that the presence of guidelines in every point of service and prices posted on walls or notes boards is an indication that the hospital is providing services as agreed in SA.
This was similarly reported in a study done on Public and private maternal health service capacity and patient ows in southern Tanzania. 23 This study reported that among six Faith Based hospitals, only two hospitals which operated under SA were not charging pregnant women when providing health services to them as agreed in the SA and the remaining four health facilities were charging pregnant women as they had not entered into SA with the government. This was different to the results reported by an evaluation study on SA conducted in China whereby barefoot doctors charged for services and did not provide health services as agreed. Other studies done in Sub Saharan Africa reported that Faith Based Hospitals charged for the service supposed to be provided free due to constant delays in reimbursements from Government. 10,11,29 Supportive supervisions, trainings and mentorship The study ndings revealed that has provided an opportunity for health workers from the private health facility to access regular training, supervision and mentorship programs from the LGAs in general and Council Health Management Team in particular. This study found that Supportive supervision is regarded as a platform whereby the supervisors and supervisees are at the same level and are able to learn from each other. Supervision is regarded as a facilitating agent for effective provision of the health services and not for doing an inspection for the mistakes. Supervision was seen as an opportunity that could help to improve the implementation of SA since supportive supervision can be used to address challenges facing the implementation of the agreement; however, the supervisions were not conducted quarterly as planned due to inadequate means of transport and delays of money. However, the hospital can use the opportunity of being frequently supervised and mentored to improve the workers' capacities hence improve the total quality of services provided. Similar ndings were reported by other studies including a study on Contracting-out primary health care services in Tanzania towards UHC 15 and Boulenger who did a study in Sub Saharan Africa on contracting between FBOs and the Public Sector in Africa. 10 Supervision of SA was seen to be weak, sometimes done by unskilled personnel and not done quaterly as planned. This was also reported in another study done in Chinaon evaluation and mechanism for outcomes exploration of providing public health care in contract service in Rural China whereby the provincial governements were not conducting supervision as agreed. 14 This study found that existence of guidelines and policies help to describe the procedures and ways that implementers of any plan need to follow in order to achieve certain results or outcomes of interest. This study found that the existence guidelines and policies on the implementation of SA is an opportunity for provision of guidance and direction by the government on how to implement, monitor and evaluate the progress of SA. These results are different from a study done by Boulenger in Sub-Saharan Africa on contracting between FBOs and the Public Sector in Africa. 12 It was reported that guidelines about SA and service provision in general were not found in Health facilities, which were implementing SA. This was noted to affect mostly the peripherial facilities. Similarly Maluka reported that there was lack of guidelines and monitoring systems related to SA implementation in some of the health facilities in Tanzania 15 , which indicate that even in Tanzania not all LGAs that have distributed the guidelines and policies to the health facilities that implement SA so as to guide them on how the SA should be implemented, monitored and evaluated. G aining political support during the implementation of SA was seen as an important opportunity for facilitating effective implementation of PPP. In this study the political in uence was rst seen at the stage of discussing and approving the municipal council Health Plans including the implementation of SA and the Health Basket Fund as main source of nancing SA in the local governments. The Councilors, who are decision makers at the local authority's level were also advocating and promoting the use of the Hospital in the provision of health services since they have seen the bene ts of SA. The same results were reported by a study on Contracting Out Non-State Providers to Provide Primary Healthcare Services in Tanzania: Perceptions of Stakeholders. 11 The study reported that there was political will of leaders to implement SA, however they were not capacitated in implementing and monitoring it. Another study done on Health contracting experiences in Sub-Saharan Africa 29 reported that the relations with the administrative authorities were cooler: there was a certain mistrust of "politics" due to a tendency of some individuals belonging to the administrative authorities to protect their own interests, particularly nancial interests.
In this study the existence of good planning and coordination mechanisms was also reported as an important factor facilitating the implementation of SA. The study found that the appointment of PPP Trust has been reported as an important factor facilitating the implementation of SA. For instance, the hospital has been well trusted by people to the extent that they can supply commodities or services expecting to be paid later on. In this study, the hospital was seen to be trusted by suppliers of medical commodities even if the Health Basket Fund delayed. This was one of the factors which made hospital to be able to provide services by having su cient drugs and other medical supplies as agreed in SA. The same nding was reported by a study done in India 32 whereby the private practitioners were not ready to enter into SA with Indian Government as it could reduce the reputations and trust of their facilities, which indicates that trust is an important factor for the implementation of SA. Another study done in East and Southern Africa 30 reported that in the relationship between Public and Private sectors the Church health services are much trusted by people due of community involvement, using a -word of God in curing people (charity) and frequent contact with people while using signs of God's presence.
In addition, the trust that has been built over time between key SA implementing parties (LGAs and the private health facility) and it was reported as one of the facilitating factors for the implementation of SA.
On other hand, the LGAs trust that the private health facility will implement its de ned roles and responsibilities whereas on the other hand, the hospital trusts that the LGAs will play its roles as de ned in the SA. Thus, trust has been a fundamental foundation for productive relationship during the implementation of SA. Similarly, the patients have also built a trust to the hospital and they regularly visit this facility for accessing health services. The results of this study are different from those results reported by a study done in China 14 which found that the patients mistrust the bare foot doctors who signed SA with Local provincial governments and preferred to go to higher government hospitals. Other two studies done in India 2017 31,32 also reported mistrust between parties whereby government accused private for submitting forged data and they are pro t oriented, which resulted to private providers to withdraw from the Contracts. Other studies done in Sub Saharan Africa also reported mistrust between parties to affect negatively the implementation of SA. 10,11,23,29 The reports submitted by another party, could not be trusted by the other party and whatever is done by other party is not trusted by the other partner. This situation posed di culties in the implementation of SA between government and Private parties.
This study also reported a number of challenges facing the implementation of SA. Saharan Africa reported similar ndings 10,15,23 whereby the introduction and the implementation of SA was seen to be presided by development partners such as GIZ in Tanzania. This affected implementation of SA because when some partners withdraw, it reduces the amount of support and sometimes delays the disbursement of funds.

Study limitations
A qualitative inquiry using key informant interviews is sometimes vulnerable to social desirability bias, resulting in some respondents particularly implementers of SA possibly over-reporting or underreporting the opportunities or challenges of implementation of SA. Bias was minimized through training research assistants to ensure neutrality and con dentiality as well as emphasizing that participant's responses would help in formulating strategies for sustainable implementation of SA in the country.

Conclusion
In summary, this study aimed at evaluating the opportunities and challenges of the implementation of SA between local Government Authority (Ilala Municipal Council) and the Mission hospital in Dar es Salaam, Medical O cer (MMO) and the Rugambwa Mission Hospital authorities. During data collection written consent was obtained from the participants before interview. The respondents were told that their participation was voluntary and they had the right to withdraw at any time during the interview.

Consent for publication
Not applicable.