1. The Government of Tanzania and Development Partners should maintain the SWAP programming format to structure their cooperation in the health sector in Tanzania during HSSP3 along with detailed adjustments and improvement aimed at streamlining review and decision making structures and processes as specified in later recommendations. (1,2 and 3)
2. The Government of Tanzania and Development Partners should make every effort to provide increased funding so that the goals of increasing per capita expenditure and of ensuring that at least 15% of national public expenditures are allocated to health can be achieved as soon as possible during HSSP 3. (1 and 2)
3. MOHSW and the Prime Minister’s Office-Regional and Local Government should agree on a target for the percentage of public health budget estimates (and expenditures) to be allocated to Local Government Authorities. This should be accompanied by improvements in systems and procedures for tracking budget allocations and expenditures. (1 and 2)
4. A Health Basket Fund and direct GoT grants to councils for the operation of health services based on a transparent resource allocation formula should remain a feature of the sector during HSSP3. Over the course of HSSP3, the Health Basket Fund may be merged with the Health Block Grant. (1 and 2)
5. HSSP3 should be used to consolidate the achievements of HSSP2 and to address identified constraints related to already agreed reforms, rather than embarking on new reforms (although some ideas for long term system changes will be offered below). (1,2 and 3)
6. HSSP3 should retain the strategic priorities of HSSP2, but should also include concrete steps to considerably accelerate progress in both hospital reform and public private partnership as set out in the detailed recommendations below. (2 and 3) 7. Effective action to reduce maternal mortality and improve delivery services,
including emergency obstetric care, should be a stated strategic priority of HSSP3. (1, 2 and 3)
8. Improving equity of access should be a cross-cutting theme of HSSP3. MOHSW should strengthen its capacity to review and modify policies and programmes with a view to improving equity and taking action to remove barriers to access. This should include the development of a strategy for improving access and establishing a focal point within the Ministry whose mandate will include all aspects of equity, including gender equity. (2 and 3)
9. HSSP3 should include specific strategies to improve efficiency of service delivery both in Primary Health Facilities and hospitals, by increasing the productivity of health sector personnel and better matching staffing levels to work loads (including piloting and, where appropriate, scaling the introduction of performance based pay). (2) 10. A health inspectorate (for which legislation has been prepared) should be established.
The Health Services Inspectorate Unit in the MOHSW should be strengthened and regional offices should be established. The MOHSW should consider the option of transforming the RHMT into regional health inspectorate units. (2 and 3)
11. HSSP3 should include the development and implementation of an overall monitor- ing and evaluation framework for the health sector which incorporates existing data collection and analysis systems and which encompasses both regular perform- ance monitoring and periodic effectiveness evaluation.
The following table briefly summarizes the conclusions of the evaluation in relation to the main evaluation criteria of the OECD/DAC and the relevant chapters in the report.
Table 9: Evaluation Findings/Conclusions in Relation to OECD/DAC Criteria
OECD/DAC Criteria
Most Important Evaluation Findings/Conclusions Relevant Chapters Relevance • Sector priorities, plans, budgets and programmes are relevant
to national goals and targets.
• Priorities are not linked to an integrated framework for monitoring and evaluation.
• The SWAP has helped maintain the relevance of external support to national goals, but GHIs and large bilateral programmes remain outside local health planning and management systems.
Chapter 3
Efficiency • Important efficiency gains can be made by matching human resources to facilities workloads and by linking resources (including pay) to performance.
• The structures and processes for sector coordination and dialogue can be streamlined to improve both efficiency and effectiveness.
• There needs to be a more effective prioritisation of the elements of publicly financed health care as summarized in the Essential Health Interventions Package.
Chapters 4, 8, 9 and 14
Effectiveness • Entry into the SWAP has resulted in greater sector coherence and the use of effective financing instruments, especially the Health Basket Fund.
• Programmes, projects and activities implemented under the SWAP have contributed to improvements in the quality of health services and to improved health outcomes (except in relation to maternal mortality and maternal health).
• While some strategic priorities (including strengthening district health services) have been effectively implemented, others have not, especially hospital reform and public private partnership.
• The benefits of improved health services need to be shared more equitably.
Chapters 3 to 14
Impact • Key positive impacts on services have been felt in the areas of continued strengths in immunization and improved
micronutrient supplementation; improved diagnosis and treatment of malaria, especially among children; improved availability of drugs; and increased use of Insecticide Treated Nets.
• Significant progress towards achieving goals in reducing infant and child mortality and some progress in aspects of child malnutrition.
• Little progress in reducing maternal and neonatal mortality. Chapter 13 Sustainability • Problems in pre-service training, recruitment, fielding, and
retention of health sector staff represent a major challenge to sustainability of health programmes and services.
• The increased share of GoT finances in the on-budget component of health sector financial resources during the evaluation period is a positive indicator of sustainability. • The GHIs and large bilateral programmes represent an
important medium and long-term challenge to sustainability of strategies and programmes.
Chapters 4, 8, 9 and 14