Examining effects of decision-making space and its practices on health systems performance in Tanzania

Lead Research Organisation: University of Dar es Salaam
Department Name: Institute of Development Studies

Abstract

Many low and middle income countries (LMICs), including Tanzania, have been implementing decentralisation since 1990s as a process to strengthen health systems and its performance through improved efficiency, quality of services and a means of promoting democracy and accountability. While decentralisation is widely practiced in LMICs empirical studies have predominantly focused on understanding the extent of the decision-making authority provided by the central government to the authorities at the lower levels. A few studies which have examined the actual use of decision-making space have focused on the influence of decentralisation on one or few health systems functional areas rather than addressing multiple functional areas. Other studies have only been conducted in a few districts making it difficult to explore how the exercise of the decision space vary across the districts and the factors that account for the variations. Additionally, studies examining the evidence for the effectiveness of decentralisation on improving health system performance are scarce and results are mixed.

Building on earlier studies, we aim to better understand how and if decentralized local authorities use decentralisation opportunities for improving health systems performance. Specific objectives are to: (i) analyse the decision-making authorities transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania; (ii) assess the actual decision-making space exercised by local government officials and district health managers within the decentralised health system; (iii) assess performance of the decentralised district health systems; (iv) investigate effects of the decision-making space on health systems performance in Tanzania; (v) engage decision makers at the national and district levels aiming at informing policy and improving the practice of decision space within the decentralized health systems

The proposed study will be carried out in 20 selected districts in Tanzania over a three-year period. The project will adopt a multiple-case study design and apply a Qualitative Comparative Analysis (QCA) approach. Purposive sampling technique will be used to select 10 best performing and 10 worse performing districts. The performance will be based on the 2018 Star Rating assessment conducted by the Ministry of Health in Tanzania.

Technical Summary

Many low and middle income countries (LMICs), including Tanzania, have been implementing decentralisation since 1990s as a process to strengthen health systems and its performance through improved efficiency, quality of services and a means of promoting democracy and accountability. While decentralisation is widely practiced in LMICs empirical studies have predominantly focused on understanding the extent of the decision-making authority provided by the central government to the authorities at the lower levels. A few studies which have examined the actual use of decision-making space have focused on the influence of decentralisation on one or few health systems functional areas rather than addressing multiple functional areas. Other studies have only been conducted in a few districts making it difficult to explore how the exercise of the decision space vary across the districts and the factors that account for the variations. Additionally, studies examining the evidence for the effectiveness of decentralisation on improving health system performance are scarce and results are mixed.
We aim to better understand how and if decentralized local authorities use decentralisation opportunities for improving health systems performance. Specific objectives are to: (i) analyse the decision-making authorities transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania; (ii) assess the actual decision-making space exercised by local government officials and district health managers within the decentralised health system; (iii) assess performance of the decentralised district health systems; (iv) investigate effects of the decision-making space on health systems performance in Tanzania; (v) engage decision makers at the national and district levels aiming at informing policy and improving the practice of decision space within the decentralized health systems

Planned Impact

The research will generate knowledge on the impact of the decision making space on health systems performance which will impact policy making at the national, regional and district levels. This knowledge has not been reported in previous studies on decentralisation in Tanzania. The findings may also help researchers, policy makers and other stakeholders to better understand how the availability and use of decision-space influence the individual building blocks and overall performance of the health system.

The research will strengthen capacity of the researchers to engage with policy makers to influence policy and practices. In this research capacity building for policy makers will be achieved through: co-design of research and implementation of the research activities; opportunities for policy makers to co-author peer reviewed journal and conference papers with researchers from Tanzania and Umeå University; participation of policy makers in national and international conferences. Similarly, policy makers will get skills on the use of evidence for policy processes.

The project provides an opportunity for a North - South collaboration that is based on mutual respect and intellectual contribution. Researchers from Tanzania will gain more research methodology skills from experienced researchers from Umeå University. In addition, the research will engage junior researchers from the University of Dar es Salaam and thus strengthen research skills and career development in the area of health policy and systems research.
 
Description Capacity building for members of the health facility governing committees, policy implementers, local government leaders and community health workers
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact This training has significantly contributed to improve performance of the health facility governing committee members. The training has also improved knowledge of the local government officials on the roles and functions of the health facility governing committees and boards in improving governance and social services delivery.
 
Description Strengthening social accountability for improving health system in Tanzania: how can health facility governing committees fulfil their role?
Amount 4,390,067 kr (SEK)
Funding ID 2780000 
Organisation Umea University 
Sector Academic/University
Country Sweden
Start 01/2022 
End 12/2024
 
Title Development of data collection tools 
Description Development of document review guide, Interview guides and questionnaires 
Type Of Material Improvements to research infrastructure 
Year Produced 2020 
Provided To Others? No  
Impact The tools were pre-tested and now used for data collection in 22 Districts in Tanzania 
 
Description Joint publications and PhD supervision 
Organisation Umea University
Department Faculty of Medicine
Country Sweden 
Sector Academic/University 
PI Contribution The partnership has resulted into securing a new research grant funded by the Swedish Research Council. The research aims to strengthen social accountability for improving health system in Tanzania.
Collaborator Contribution This project therefore aims to understand if, how, and under what conditions informed and competent (HFGC) improve social accountability. This will be achieved by using a participatory approach to realist evaluation, engaging members of the HFGCs, health managers and providers and community leaders to: 1) map challenges and opportunities of the current reform; 2) develop an initial programme theory that proposes a plan to strengthen the role of the HFGCs; 3) test the programme theory by developing a plan of actions; 4) refine the programme theory through multiple cycles of participatory learning and finally 5) propose a set of recommendations to guide processes to strengthen social accountability in the Tanzanian health system.
Impact -Joint research proposal development -Joint publications -Joint PhD supervision -Joint capacity building for early career researchers
Start Year 2021
 
Description Joint research collaboration 
Organisation Umea University
Country Sweden 
Sector Academic/University 
PI Contribution We worked together to develop research project
Collaborator Contribution It has made it possible to jointly apply and win a new research grant with builds on the current reasearch
Impact Joint application for research funding
Start Year 2023
 
Description Joint research proposal aimed to improve social accountability for improving health system in Tanzania 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Department Department of Infectious Disease Epidemiology
Country United Kingdom 
Sector Academic/University 
PI Contribution The award led to emergency of new research collaboration between University of Dar es Salaam and Umeå University in Sweden. The collaboration resulted into a joint research proposal writing which was submitted for funding to the National Institute of Health and Care Research (NIHR)
Collaborator Contribution The University of Dar es Salaam was a lead applicant in a new research collaboration between Umeå University, London School of Health and Tropical Medicine, Ministry of Health Tanzania and the University of Dar es Salaam. This new research collaboration aims to strengthen social accountability in primary health care facilities for improving the performance of health services. This will be achieved by using a participatory approach to realist evaluation, engaging Committee members, health managers and providers, and community leaders to: 1) map challenges and opportunities of the current reform; 2) develop an initial programme theory that proposes a plan to strengthen the role of the Health Facility Governing Committees; 3) test the programme theory by developing a plan of actions; 4) refine the programme theory through multiple cycles of participatory learning and finally 5) propose a set of recommendations to guide processes of scaling and institutionalisation of social accountability mechanisms into the health system. This project leverages implementation research expertise at the London School of Hygiene & Tropical Medicine and builds on existing Swedish Research Council funded collaborative research between University of Dar es Salaam and President's Office - Regional Administration and Local Government (PO-RALG) in Tanzania and Umeå University providing true opportunities for action learning and close interactions between researchers, decision makers, practitioners, community members and other stakeholders.
Impact The collaboration resulted into joint research proposal writing
Start Year 2023
 
Description Debriefing sessions with study participants and policy makers 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact This research is conducted in 22 Districts in Tanzania. We are now in the process of collecting data. Data are collected at the District, District Hospital, Health Centres and Dispensaries in all 22 District. In each district data collection exercise starts with brief discussion with potential participants. Participants are given information about the objectives of the research and expected results of the research projects. They are given opportunity to ask questions and get clarifications.
Year(s) Of Engagement Activity 2020,2021
 
Description Engagement with District and community policy makers and implemnters 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Baseline data collection using semi-structured interview guides
Year(s) Of Engagement Activity 2021
 
Description Findings dissemination workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact 55 participants attended findings dissemination workshop. Researchers got opportunity of disseminating research findings to key policy makers and implementers. The dissemination workshop resulted into fruitful discussion on how the government and other stakeholders can further strengthen local health systems in Tanzania.
Year(s) Of Engagement Activity 2023
 
Description Research findings validation and dissemination workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact 65 people attended the dissemination workshop and got opportunity to share and discuss on the findings of the research
Year(s) Of Engagement Activity 2023
 
Description Sensitisation of community members on the social accountability for primary health care service delivery 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact More than 1000 members of the public are being sensitised on the roles, functions, and activities of the health facility governing committees. Our research revealed that the vast majority of community members were not aware of the activities of the health facility governing committees. Members of the community were not aware of their roles in supporting activities of the health facility governing committees in order to improve social accountability at the primary health care facilities. The community members and the research team jointly developed interventions aimed to raise awareness of the community members with an ultimate goals of improving social accountability for primary health care services delivery.
Year(s) Of Engagement Activity 2023,2024
 
Description Training of community health workers, Community leaders and most influential people in the communities. 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact 76 people attended training on the roles and functions of the health facility governing committees in improving social accountability for primary health care services delivery. Our research identified lack of awareness of the community members of the roles and functions of the health facility governing committees and their involvement in the activities of the committees.
Year(s) Of Engagement Activity 2023,2024
 
Description Training of health facility governing committee members 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Members of health facility governing committees were trained on their roles and functions, social accountability and planning and budgeting processes. This training was aimed to strengthen their capacity in improving social accountability at the primary health care facilities. Our research identified limited capacity among members of the health facility governing committees.
Year(s) Of Engagement Activity 2023