Perspectivas para el futuro de los sistemas EBC

ENVIRONMENT

This section offers concrete recommendations and next steps to foster a more positive environment to harness and grow the private health sector in Tanzania.

Strengthen national capacity to effectively regulate, supervise, support, and assure quality of health services and goods in both the public and private sectors.

The PSA revealed three key regulatory areas that can improve the quality of private health services: 1) strengthening national standards for accreditation and quality assurance; 2) streamlining facility licensing process; and 3) requiring CPD for professionals to renew their licenses. Given the importance of these reforms, the PSA team recommends consistently involving private sector leaders and representatives from the start in a consultative process. The MOHSW can work through the National PPP Steering Committee to spearhead this process. Address barriers to private health sector access to affordable finance.

The PSA team recommends a multi-pronged approach to increase access to credit and strengthening private providers‘ business skills. 1) Work with APHFTA on improving the business management training materials for private health providers. 2) Develop a DCA guarantee for the health sector and work with financial institutions to expand health sector lending, through training bank staff as well as developing new products such as leasing. 3) Analyze the level of profitability for various types of health businesses in Tanzania to gauge whether loans are affordable (and whether interest rates are too high).

Target and harmonize incentives for private health sector actors delivering identified essential health services.

Private providers interviewed stated that high taxes and levies can deter them from expanding their preventive and curative essential health services. For example, PFP providers are

penalized through taxes when they expand services, and they pay higher costs to access needed equipment and drugs even when used for government priority health services. This is also an issue for many FBO/NGOs; although they are tax exempt, they still pay levies which contribute to increasing service delivery costs. The investment branch at TIC described a simple process to apply for tax relief: the facility or organization submits a proposal that 1) analyzes tax/tariff/value added tax impact; 2) makes the case that tax/tariff/VAT limits private sector development, economic growth, and job creation in the health sector; and 3) explains how growing the private health sector also provides a public good (e.g., health impact). TIC responds to proposals within six months.

Establish and strengthen institutions and processes for effective public-private dialogue. There are different strategies needed to put into place the institutional arrangements needed to facilitate greater public-private sector interactions. In the case of the public sector, the

government needs to invest in building the systems and capacity of the key entity charged with engaging the private sector – the PPP Unit. The private sector, on the other hand, needs to get

organized by creating new structures that represent key sub-groups. Finally, the National PPP Steering Committee should transform into a sector-wide level.

MOHSW and PMO-RALG.

Although PMO-RALG has recently made efforts to strengthen its relationships by assigning six new full-time staff to work directly with MOHSW, more needs to be done. Involving the PMO-RALG actively and systematically in key MOHSW functions and processes will help strengthen the relationship and improve coordination between policy and implementation of health services. Moreover, bringing PMO-RALG closer will also help the integrate private providers into the overall health system The nexus between the public and private health sectors is the CCHP process in which budgeting and planning decisions, including

coordination between the sectors, are made. PMO-RALG has established guidelines on how to carry out the CCHP process. The PPP Unit can work more closely with PMO-RALG to ensure that the guidelines include other key stakeholders in health like the private sector. MOHSW PPP Unit’s capacity.

The MOHSW has put into place a comprehensive policy framework supporting PPPs in the health sector, but it has been slow to develop a substantial number and broad range of health PPPs. The primary constraint is the PPP Unit‘s limited capacity. The PSA

recommends that MOHSW and donors fully invest in the health PPP Unit in the following areas: 1) increasing the number of PPP Unit staff; 2) training a core group in new skills areas; 3) standardizing operating systems to build, track, and assess PPPs; 4) training central- and regional-level staff in new operating systems; and 5) assisting PPP Unit staff to broker the first round of health PPPs.

Umbrella organization for the private health sector.

The health PPD forum‘s success rests on two crucial assumptions: 1) an organized private health sector and 2) strong member organizations. There is still considerable room to further organize the private health sector. The PSA team determined that many of the recommendations proposed in HERA 2005 to structure the private sector have not been implemented, due in large part to lack of trust and suspicion between the sectors. Lack of organization of the private health sector will jeopardize the NPPPSC‘s ability to foster dialogue and create meaningful exchange between the sectors. The PSA team believes there has been a substantial change in attitudes and perceptions between the two sectors, and that the timing is right to ―push‖ the Tanzanian private health sector to get organized. Elevate public-private dialogue to a sector-wide level.

Even though the PPP-TWG has been an effective and productive PPD forum in health, all the PPP-TWG members interviewed noted a need to formally establish the National PPP Steering Committee as a sector-wide forum. Formalizing the NPPPSC will address many of the PPP institutional and organizational gaps identified in the analysis.

 It will create a space for all private health sector groups to discuss health system issues that directly impact their constituencies. Moreover, the forum will allow the various private actors to participate more consistently with the MOHSW in policy and planning at the national level.

 It will incentivize the different sectors, such as the professional associations and larger health NGOs, to organize themselves, by providing a purpose and a forum for them to advocate. Moreover, as the sectors organize and effectively dialogue with the MOSHW, groups like the CSSC may be supported to revive the Tanzania Interfaith Forum initiative to form a powerful inter-group.

 It can join the TPSF and fully represent all the private health sector interests in national forums like the TNBC. Participation in such a national forum will give the health sector the focus and attention it merits, given its economic size and development importance. To avoid becoming a ―talk shop‖ in which few decisions are made and no actions are taken, it is important that the sector-wide forum be defined as ―problem driven and action oriented‖ by narrowing its activities to focus on concrete actions in which the public and private sector can work together. Examples include addressing market barriers (e.g., tax structure), public-private collaboration to accelerate TB control, and expanding health services to under-served areas through existing infrastructure (including private health sources). Strengthen information sharing and networking at all levels.

A short-term win is to bring together the public and private sector to agree on key health

indicators that they will regularly report on to the MOHSW. In exchange, the MOHSW will agree to share more widely ministry plans and reports to help inform the private sector on government priorities. Another ―quick win‖ is to review the annual meeting and planning processes at the national and district level to identify opportunities to involve the private sector. Two examples include inviting a wider range of private sector groups to participate in the Annual Health Sector Review and to clarify the norms guiding the CCHP process to identify and involve key private sector groups in each council and district.

4. SERVICE DELIVERY IN THE