The period under review has seen improvement in funding levels for regional hospitals. Regional hospitals have also been able to raise additional revenues through the collection of user fees, the introduction of private wards, where affluent patients receive better serv- ices for a higher price, and through direct donor support.
Where regional hospitals also serve as the council hospital, they are allocated the HBF funds earmarked for the district hospital(s). Now that several Councils are building long- awaited council hospitals, these funds will be re-allocated to the new council hospital, seriously diminishing the financial resources of the regional hospital.
One could of course argue that the new council hospitals will take over a good share of the (less complicated) cases that now present to the overcrowded regional hospitals, there- fore justifying a decrease in budget for the latter. However, regional hospitals are in gen- eral severely under-funded (and very heavily used) as it is, so any cut in revenues will impact negatively on their ability to provide quality services.
The district case studies noted other persistent challenges in funding the regional hospi- tals including:
• Continued delays in transfer of funds;
• An overall inadequate MSD allocation for drugs and supplies;
• Lack of financial management capacity, resulting in poorly prepared, and sometimes rejected, budgets;
• The fact that regional hospitals feel obliged to accept funding driven by specific donor interests, often not integrated into their planning and budgeting structures and sometimes not in accordance with priority needs.
Governance and Management
While Health Management Teams are established and functioning in many regional hos- pitals, like district hospitals, most do not yet have Hospital Boards in place. Only one of the regional hospitals visited by the evaluation has several reform experiments in place, due to the fact that its Director is a member of the National Hospital Reform Task Force. In general it was observed that whatever reforms in governance were taking place, these were more a result of local and individual initiatives than that they were facilitated by national guidance.
There has been some improvement, albeit slow, in the management capacity of the regional hospitals. Prior to health sector reform, managers were used to planning for resources on an incremental basis (approx. 10% per annum). Coupled with their low expectation of receiving the amounts budgeted for, this acted as a disincentive to proper planning and budgeting.31 Training of RHMT members in management practices has
resulted in better management capacity, but whether these skills are also routinely uti- lised for improved hospital planning could not be established.
Infrastructure and Equipment
During the evaluation period, infrastructure development for hospitals has been very slow. The JAHSR noted in 2005 that physical rehabilitation of district and regional hos- pitals had not yet started.32 The low level of investment towards the rehabilitation of hos-
pitals is reflected in the Development Expenditure Budget for Rehabilitation of (all) Facilities. In FY 2003/04, this was 11.5% of the total budget allocated to financing prior- ity health interventions. In the same year, the budget for strengthening referral hospitals was 14.7% of the total. Projections made for the FY 2004/05 and 2005/06, showed a similar trend.33
Even in regional hospitals, the utilities infrastructure remains very poor, both water and electricity supplies being intermittent at best. In many facilities, (in contrast to FBO facilities) the use of captured rainwater (in plastic tanks, for example) and identification of viable alternative power sources is not being pursued proactively.
31) Sector-Wide Approach in Tanzania: The Health Sector Example; Oliver Burki (Swiss Agency for Development and Cooperation), February 2001.
32) Progress against the Milestones set in March 2004 to Joint Health Sector Main Review (4th-5th April,
2005).
The condition and availability of equipment however, has faired better in regional hospi- tals, and this has been largely associated with bilateral donor support. Ten regional hospi- tals received VHF radio-calls, office equipment, computers and emergency supplies and equipment. Four regional hospitals are documented to have received ambulance vehi- cles.34 It must be stressed however, that transport and communication remain a severe
problem.
The quality of equipment received from MOHSW through MSD has improved in the period under review, but still remains inconsistent and is said to be lower than the qual- ity of equipment available from other suppliers. Maintenance of equipment however is still poor. Preventive and systematic maintenance practices are lacking and equipment is repaired, if at all, on an as-needs-emerge basis. Most hospitals lack the local technical capacity or support to effect necessary repairs.
Drug Supplies
Interviews and observations from the six district case studies indicate some improvement during the evaluation period in the supply of drugs to regional hospitals. However, there are still delays from MSD and shipments are often reportedly missing from 10 to 20% (reported by Mawenzi Regional Hospital, Kilimanjaro) or even 50% (Sekou-Toure Regional Hospital, Mwanza) of drugs ordered. Drug allocations are not based on the (real) burden of disease and some regional hospitals report that as little as 20 to 30% of their real drugs and supplies needs are actually met. On the other hand, regional hospi- tals have more cost-sharing revenues than district hospitals and are able to cover part of the shortfall by using these revenues to purchase additional drugs in the market.
On the positive side, the supply of anti-malarials and anti-retroviral drugs (ARV) has been consistent and stock-outs are now rarely experienced.
Human Resources
In spite of the improvements over the last few years (the emergency hiring programme, increase in public health worker salaries, etc), regional hospitals still face severe shortages of qualified staff while workload remains high. With no concrete Human Resources for Health (HRH) attraction and retention strategies in place, hospitals in hard-to-reach areas are particularly affected. Some extreme examples of the severity of the crisis include Singida Regional Hospital which currently has no medical officer. Sekou Toure is run mostly by Assistant Medical Officers (AMO). It is already difficult to find MOs in regional hospitals and medical specialists are even more scarce.