Community participation in the decentralised district health systems in Tanzania: why do some health committees perform better than others?

THE INTERNATIONAL JOURNAL OF HEALTH PLANNING AND MANAGEMENT

Int J Health Plann Mgmt 2016; 31: E86–E104 Published online 5 June 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hpm.2299

Community participation in the decentralised district health systems in Tanzania: why do some health committees perform better than others? Stephen Oswald Maluka1* and Godfrey Bukagile2 1

University of Dar es Salaam, Institute of Development Studies, Dar es Salaam, United Republic of Tanzania 2 College of Business Education, Development Studies, Dar es Salaam, United Republic of Tanzania

SUMMARY Over the past two decades, community participation has emerged as an important dimension within decentralised district healthcare systems. In Tanzania, initiatives to strengthen community participation have focused on the formation of the health committees. Studies have reported variations in the performance of the committees. An exploratory case study design focusing on two districts was adopted to explore the differences in practice of the health facility committees in a well-functioning district and one that is not. In both study districts, the committees were in place. The most common activities of the health committees were assisting the clinic in day-to-day running. The health committees’ influence on policy, planning and budgeting was limited. Managerial and leadership practices of the district health managers, including effective supervision and personal initiatives of the top-district health officials coupled with incentives, are the major factors for the good performance of the health facility committees and the boards. Inadequate training and low public awareness affected the performance of the committees. A greater role in governance and oversight is essential for effective and meaningful health committees. To achieve impact, health committees will require adequate training on the following: roles and functions of the health facility committees and the boards; interaction between the committees and the communities and the health workers; development of health plans and budgets at the local and district level; and monitoring and tracking. Copyright © 2015 John Wiley & Sons, Ltd. KEY WORDS:

community participation; health systems; health facility committees; Tanzania

BACKGROUND Community participation is a key principle in the primary healthcare approach. The expected results of community participation include better governance of the health *Correspondence to: S. O. Maluka, Institute of Development Studies, University of Dar es Salaam, Box 35169, Dar es Salaam, United Republic of Tanzania. E-mail: [email protected]

Copyright © 2015 John Wiley & Sons, Ltd.

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system; enhanced community voice, empowerment of the marginalised groups; responsiveness of service providers and policy makers to citizens’ demands; a reduction in corruption; and, ultimately, the achievement of health outcomes including enhanced quality of care, appropriateness of health service delivery for users, and patient satisfaction and utilisation of health services (WHO, 1978, 2008; Cornwall et al., 2000; World Bank, 2004). There are different ways of conceptualising community participation—from forms of participation where participants are passive recipients to forms of participation where citizens are part of the decision-making process. Arnstein (1969) defines participation as citizens’ power and develops a ladder with different forms of participation with eight different ‘steps’ signifying an increase in participants’ power. The first two steps—manipulation and therapy—are according to Arnstein (1969), designed by those in authority to control any pressure for accountability. In the following three steps—informing, consultation and placation—there are degrees of participation insofar as participants are allowed to have a voice and to advise. But it is not ‘genuine participation’ because it ‘lacks power to ensure that people’s views will be heeded by the powerful’ (Arnstein, 1969:217). The next step towards what Arnstein calls ‘genuine participation’ is a partnership where citizens and powerholders agree to share planning and decision-making responsibilities. A further step occurs in ‘delegated power’ where citizens achieve a dominant decision-making authority over a particular plan or programme. Finally, ‘citizen control’ completes the ladder, where participants govern a programme or an institution. Potts (2009) defines active and informed participation as including participation in the following: identifying overall health strategy, decision-making, prioritisation and setting the agenda for discussion. This includes involvement of people in policy choices, implementation and monitoring and evaluation. Power-sharing between community members and health managers or officials is, therefore, essential to meaningful participation (Potts, 2009). In Tanzania, community participation is part of a wider health sector reform of the early 1990s, which aims at doing away with centralised health system and replacing it with decentralised district health system. Within these new structures, the central government is pushing the responsibility for planning and delivery of health services closer to the communities, and the civil society and the citizens are being asked to play a greater participatory role in these processes. Several structures that are important in facilitating citizen participation have since been established at the local government and at community levels. These structures include Council Health Service Boards (CHSBs) and health facility committees (hospital committees, health centre committees and dispensary committees). The health facility committees are tasked with strengthening community-level decision-making about facility matters, including fund-related decisions. The health facility committees are also a mechanism for the community members to get involved in advocating for enhanced service delivery. Table 1 summarises composition, functions and roles of health facility committees and boards. Globally, several reviews have summarised the state of knowledge in the area of community participation, noting the mixed results that have been achieved. Glattstein-Young (2010) demonstrates that some health committees in the greater Copyright © 2015 John Wiley & Sons, Ltd.

Int J Health Plann Mgmt 2016; 31: E86–E104 DOI: 10.1002/hpm

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S. O. MALUKA AND G. BUKAGILE

Table 1. Composition, functions and roles of the health facility committees and boards in Tanzania (URT, 2001) Composition

Functions and roles

The CHSB consists of 11 members: four non-vote members (DMO, RHMT, a planning officer and a representative from the hospital) and seven vote members including four elected community members of whom at least two should be female. Other three members are two representatives from private service providers and the chairperson of social services committee of the council -Qualification is secondary education and above and aged 25–70 years

Identify, mobilise and solicit financial resources Ensure delivery of healthcare services Discuss and approve health plans, budget and reports from the CHMT Support CHMT in managing and administering health resources Promote community involvement through sensitisation

CHMT consists of eight core members: the DMO (chairperson), a nursing officer, a laboratory technician, a health officer, a pharmacist, a dental officer, the District Health Secretary (secretary) and the Social Welfare Officer. The co-opted members may be invited as the need arises

Prepare district annual health plans Ensure implementation of health activities by hospitals, health centres, dispensaries and communities Monitor and evaluate implementation of health activities in the district.

The hospital governing committee is established at the hospital and consists of 10 members: seven vote members (two service users, one from health centre committee, the District Commissioner, one from voluntary facility one member from private for profit and one from NGO) and three non-vote members (a medical officer in charge, office of the DMO and a representative from the CHSB) -Qualification is secondary education and above and aged 21 years and above

Oversee management of resources at the hospital Discuss and pass proposals and budgets for the hospital and submit to the council through CHSB Discuss implementation report from hospital management team Inform communities on hospital plans and its implementation.

Health centre committees are composed of eight members: six vote members (three service users, one from dispensary committee and two from private providers) and two non-vote members: head of the facility and one from WDC. -Qualification is primary education and above and age at least 21 years.

Discuss and pass health centre plans and budgets Identify and solicit financial resources for running health centre Ensure delivery of healthcare services

Dispensary committees are composed of eight members: five vote members (three service users and two from private providers) and three nonvote members (one from WDC, one from a village government and one head of the dispensary). -Qualification is secondary education and above and aged 25–70 years

Discuss and pass dispensary plans and budgets Identify and solicit funds Ensure delivery of appropriate services

CHSB, Council Health Service Board; DMO, District Medical Officer; RHMT, Regional Health Management Team; CHMT, Council Health Management Team; NGO, nongovernmental organisation; WDC, Ward Development Committee.

Cape Town area were successfully involved in ensuring that a day clinic changed into a 24-h-facility. Loewenson et al. (2004) found out, in a study in Zimbabwe, that clinics with health committees generally had more staff, expanded programmes Copyright © 2015 John Wiley & Sons, Ltd.



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and better drug availability. In Peru, local health committees were reported to have had effectively identified unmet health needs at the local level, generated and effectively allocated resources and met those needs and developed a payment scheme that protected the poorest groups (Iwami and Petchey, 2002). In their literature review, Padarath and Friedman (2008) concluded that community participation provides an opportunity for community members and health care workers to become active partners in addressing local health needs. McCoy et al. (2011), in a systematic review, concludes that the health facility committees are not a simple and ready-made solution to the problems of poor health services. But they can have a positive impact provided they are designed and implemented with care (McCoy et al., 2011; Molyneux et al., 2012). Despite its potential impact, community participation is fraught with problems, and in some cases, it is both ineffective and limited. For example, a number of studies suggest that health committees in South Africa are not functioning optimally (Padarath and Friedman, 2008; Glattstein-Young, 2010). Numerous factors impact on their functioning. These include lack of political commitment, limited resources, limited capacity and skills, attitudes of health workers, lack of clarity of the role and mandate of committees, limited co-operation from health services and lack of support. Likewise, in Tanzania, studies have reported mixed results on the functioning of the health facility committees and the boards. For example, a study conducted by the Research on Poverty Alleviation concluded that citizen participation in the planning and implementation of development activities at the local level is yet to be realised (Research on Poverty Alleviation, 2008). Similarly, Ministry of Health and Social Welfare (2007) found out that in some districts, bottom-up planning was in practice an ad hoc exercise, with the actual planning carried out only by the Council Health Management Team (CHMT) with no element of community participation. Mubyazi et al. (2007) described community participation as ‘rhetoric’ rather than ‘reality’. On the other hand, Kessy (2008) documented several achievements of the health facility committees and the boards. These included the following: reprimanding irresponsible health workers; following up on the issues of staff recruitment and drug stock out; following up issues related to mismanagement of patients; and rehabilitation and construction of health facilities. However, in all districts, there were critical issues that affected the performance of the committees and boards. As a result, while these institutions were considered important in some districts, their relevance was questioned in other districts (Kessy, 2008). Other studies found out that the health facility committees were effective in tackling issues relating to health workers’ performance, community–provider relations and revenue generation (Ndunguru, 2008; IHI, 2011). Trust and relationship with other actors and leadership among the village government and other actors as well as district support were critical to the success of the committees (IHI, 2011). This study, therefore, aimed at explaining the differences in practice of the health facility committees in a well-functioning district and one that is not. A framework to analyse the functioning of the health committee was based on health committees’ description of what they do, but using the works of Potts (2009) and Arnstein (1969) as references. Copyright © 2015 John Wiley & Sons, Ltd.


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Table 2. Key characteristics of the study settings

Population Community Health Fund enrolment rate* Hospitals Health centres Dispensaries Divisions Wards Villages Health workers available Shortage of health workers

Iramba District

Lindi District

236 282 people 28.1% 2 6 60 7 31 143 43% 57%

194 143 people 0.4% 1 6 30 9 30 134 50% 50%

*The national Community Health Fund coverage rate is about 7.9% (National Health Insurance Fund data of 2011).

METHODOLOGY The study design and settings The study was conducted in the following two rural districts in Tanzania mainland: Iramba and Lindi district councils. The two district councils were purposively selected based on how they have been performing in the Community Health Fund (CHF) operations.1 Therefore, one district council that has been reported to perform well and one that appeared to be weak in CHF performance were selected. In carrying out the study, the CHF was used as a criterion for selecting the districts because it has a strong component of community participation. However, the districts were not selected based on performance only; other factors such as accessibility were taken into account. Table 2 summarises key characteristics of the study settings. In each district, one hospital, two health centres and four dispensaries were purposively selected, with the assistance from the district medical office. The selected entities included health facilities where health committees were perceived to perform poorly and those that were reported to have performed better.

Data collection techniques. The study on which this paper is based combined a mixture of data collection techniques including analysis of documents, interviews with key stakeholders, survey questionnaire and health facility visits. First, documents were used to examine the conditions at the national level, which encouraged or discouraged the functioning of health committees generally. Documents that were reviewed included the following: guidelines for the establishment of the committees and the boards as well as planning and priority-setting guidelines. In addition, minutes of meetings of the committees and the boards, lists of participants and schedules of meetings were used to support, verify and highlight key issues pointed out by the respondents involved in the study. 1 Community Health Fund performance data were obtained from the budget speech of the Ministry of Health and Social Welfare 2011/2012 and 2012/2013.



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Second, based on the interviews with the key stakeholders, the study analysed the actual involvement of the health committees in the district health planning, decisionmaking and service delivery. The study also assessed evidence of positive benefits of the health committees and value added by the inclusion of citizens in the governance of district health systems. In Iramba District, individual interviews were carried out in October 2012, while in Lindi, the study was conducted in January 2013. In each case, interviews lasted for approximately 45 min and were carried out at the respondent’s workplaces and/or home. In order to cover a wide range of views from different levels of the district health system (dispensary, health centre and the district), a purposive sampling technique was used. Interviews were carried out until saturation was reached, which the point at which no new information could be indentified in successive interviews. In total, 83 interviews were carried out (51 interviews in Iramba and 32 interviews in Lindi) (Table 3). Third, in all health facilities visited, structured exit interviews were conducted with a target sample of 30–50 community members seeking outpatient services. Interviews went hand in hand with administering questionnaires that in which case, a total of 449 completed questionnaires were obtained; 231 questionnaires in Iramba and 218 questionnaires in Lindi District. Data were collected with the intention to solicit information on awareness of the community members about the existence of health facility committees and their involvement in the district health planning, decision-making and service delivery. Finally, facility visitations were made in order to verify and validate key issues that were reported by the respondents. Issues observed included announcements and other documents posted on the notice boards, and construction and rehabilitation of the health facilities. Data analysis The Statistical Package for Social Sciences (SPSS, IBM, Armonk, NY, USA) was used to analyse the quantitative data generated through structured questionnaire. Other quantitative data that were recorded in numerical form were entered into an Excel worksheet for secondary analysis of totals, percentages and other such simple statistics as necessary. Thematic approach was adopted to analyse interviews. First, all the interviews were transcribed into Swahili verbatim. Second, the transcriptions

Table 3. Categories of key informants Category of respondent Ordinary citizens Member of staff (health service providers) Elected local officials Local government employees District health managers District level government employees Total Copyright © 2015 John Wiley & Sons, Ltd.

Number interviewed Iramba

Lindi

24 12 2 8 3 2 51

17 7 1 4 3 — 32


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were translated into English for reference purposes. Third, a code manual was developed based on the research questions. Fourth, the transcripts of each interview were read through, and responses were identified to the main questions raised by the study and were then entered into NVIVO 10 software for storage (QSR International Pty Ltd, Australia), coding, text search and retrieval. Using NVivo 10 software, data were coded to initial themes. Thereafter, data were sorted and grouped together under patterns that were deemed precise, complete and generalisable. As patterns of meaning emerged, similarities and differences were identified. Finally, data were summarised and synthesised, retaining as much as possible the key terms, phrases and expressions of the respondents. After this analysis, data were triangulated to allow comparison across different categories of respondents and subsequently discussed for final interpretation and presentation of the results.

THE KEY FINDINGS This section summarises the key findings based on the analysis of in-depth interviews with key informants, analysis of minutes, survey with the outpatients, and health facility observations by the researchers. Findings are organised according to the themes that emerged during the interviews. Quotes are used to illustrate and support points, with the position and health service location of the quoted interviewees described in brackets after each quote. The key characteristics of survey respondents In Iramba District, 169 respondents (73.6%) were females, and 62 respondents (26.4%) were males. Similarly, in Lindi District, 142 respondents (66%) were female, and 73 respondents (34%) were male. In Iramba District, 192 survey respondents (83.1%) were farmers, and 167 respondents (72%) had attained primary education. A similar pattern was revealed in Lindi District, whereby 187 respondents (86%) were farmers and 117 respondents (54%) had attained primary education. However, the number of those who had never gone to school was higher in Lindi District where there were 73 respondents (34%) and lower in Iramba District where there were 30 respondents (12.9%). Table 4 summarises key demographic characteristics of the survey respondents. As for the CHSBs, hospital governing committee, and health centre and dispensary committees, the committee members included the head of the health facility (health facility incharge) as a secretary and between 8 and 11 members. In all health centre and dispensary committees and the CHSBs, the chairperson was elected from ordinary community members. The majority of the community representatives were farmers although for the hospital governing committee and the CHSBs, they were retired civil servants and business people. Selection process and the capacity of health committees and boards For the CHSB, in both study districts, all district health officials reported that the District Executive Directors had advertised vacant posts for representatives from Copyright © 2015 John Wiley & Sons, Ltd.


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Table 4. Key demographic characteristics of the survey respondents Lindi rural Sex Female Male Total Occupation Farmer Employed Business Student Others Total Level of education Never gone to school Primary education Secondary education Diploma University Total

Iramba

N

%

N

%

142 73 215

66 34 100

169 62 231

73.6 26.4 100

187 9 9 9 4 218

86 4 4 4 2 100

192 8 14 8 9 231

83.1 3.5 6.1 3.5 3.9 100

73 117 25 2 1 218

34 54 12 1 1 100

30 167 35 0 0 232

12.9 72 15.1 0 0 100

the community. Qualifications for members of the board included: secondary education or above, not more than 70 years of age, and the requirement for a member not to be employed by either the central or local government. According to the respondents, the selection of board and committee members was carried out by the District Executive Director’s office, after being scrutinised by the Ward Development Committees. However, interviews at the district level indicated that sometimes, the district council faced difficulties in attracting people with relevant qualifications, the most problematic requirement being the level of education. Sometimes, the district authorities were forced to re-advertise. Nevertheless, the boards in both study districts had a track record of attracting members who were highly qualified for the positions that had been advertised. For instance, in Iramba District, in the former board, one member was a retired district planning officer with a bachelor’s degree. During the time of this study, the chairperson of the board was a former headmaster with a diploma in education. As for the health facility committees, almost all district health managers reported that advertisements had been issued by Ward Executive Officers on behalf of the District Executive Directors. Qualifications included the following: completion of primary education and the ability to read and write at least in Kiswahili, the national language and not holding any elected post through any political party. The applications and selection were carried out at the village level and supervised by Village Executive Officers and Ward Executive Officers for dispensary committees and health centre committees, respectively. A list of the selected candidates was forwarded to the Ward Development Committees for final selection and to the district council for endorsement. Copyright © 2015 John Wiley & Sons, Ltd.


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However, further analysis of the data revealed that sometimes, this process was not followed because most often, people did not apply for these positions. Ward Development Committees, in collaboration with the incharges of the health facilities, were forced to nominate people who were willing to take these positions. For example, 10 members of health facility committees representing the communities (66.6%) in Lindi district reported that they had not applied for the posts. They were, instead, nominated by either the village and ward leaders or the health facility incharges. When asked how they joined the health committees, some respondents remarked as follows: The first day I found a message at home asking me to report to the Ward Executive Officer. When I went there, I was told that any time I would receive a letter and I should accept it. I have been nominated to join the health facility committee. A few days later, I got the letter and I accepted the post (IDI with HFGC member in Lindi). Another respondent added as follows: I was nominated to join the health facility committee because in 2006 I attended Home Based Care (HBC) training (IDI with HFGC member in Lindi). Similar experiences were reported in Iramba District. When asked how they were selected, some of the respondents put it this way: To be honest, I can say I was appointed. I just received information from the village executive officer that I have been selected as a member of the health facility committee (IDI with HFGC member). Another respondent added as follows: Sometimes you may advertise for the post but people do not apply. As you know, this is a voluntary kind of work with no payment. People feel like they are wasting their time. Therefore, sometimes we are forced to request the few who have applied to nominate other members who may be willing to join the committee (IDI with in-charge of a health facility). Analysis of questionnaire revealed that in both study districts, most of the community members did not participate in selecting the health facility committee members (Table 5). Table 5. Participation of the community members in selecting members of the committees Iramba

Lindi rural

Have you ever Participated in selecting the members of the following committees?

N

%

N

%

N

%

N

%

Village HIV/AIDS Committee Village Health Committee Ward Health Committee Council Health Services Board

34 35 28 2

14.8 15.3 12.3 0.9

195 194 200 227

85.2 84.7 87.7 99.1

22 16 13 7

10 8 6 3

194 198 203 208

90 93 94 97

Yes


No

Yes

No


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Furthermore, the majority of the members of the community were unaware of the existence of the health facility committees, and the boards leave alone their roles and responsibilities (Table 6). Achievements of the committees and the boards In Lindi District, a few respondents reported that the committees have recorded success in terms of monitoring the performance of health workers, management of drugs at the facility and supervising the rehabilitation and construction of the health facilities. Some respondents remarked it this way: We have managed to supervise the construction of health facilities including Mchinga, Namangale, Namupa and Chiuta dispensaries. All these health facilities are functional (IDI with CHSB member). The major achievement is the supervision of the construction and minor rehabilitation of health facilities (IDI with HFGC member). Almost all respondents pointed out that the health facility committees were involved in the management of drugs. Every time when drugs were brought to the facility, one or two members of the committees were called to verify the receipts and the vouchers. According to the vast majority of respondents, this system has largely reduced the possibility of drug mismanagement by the health workers. However, six members (20%) felt that they had nothing to celebrate because CHF enrolment in their health facilities was extremely low. One respondent explicitly put it this way: In my opinion, to a great extent the committee has failed because we have recorded very low enrolment rate in the Community Health Fund (CHF). CHF is very important for the performance of the facility as it may generate financial resources for the facility (IDI with health facility committee member). Table 6. Knowledge of the communities about health facility committees and boards Iramba Yes

Lindi rural No

Yes

No

Have you ever heard about the following committees?

N

%

N

%

N

%

N

%

Village HIV/AIDS Committee Village Health Committee Ward Health Committee Council Health Services Board

103 99 80 35

44.4 43.6 35.6 15.3

129 128 145 194

55.6 56.4 64.4 84.7

92 78 51 30

42 36 24 14

125 136 164 186

58 64 76 86

55 62 43 2

24.6 27.1 18.9 0.9

169 167 184 226

75.4 72.9 81.1 99.1

42 44 25 13

19 20 12 6

174 172 190 203

81 80 88 94

Do you know anybody who is a member of the following committees? Village HIV/AIDS Committee Village Health Committee Ward Health Committee Council Health Services Board Copyright © 2015 John Wiley & Sons, Ltd.


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Similar view was expressed by some health facility incharges and health professionals. The major role of health facility committee is to ensure that people are enrolled in the CHF and get health services. In this regard, I can reasonably say that the committee has failed. CHF enrolment in this area is very low (IDI with in-charge of a health facility). Households were required to contribute 10 000/= annually. This premium covered a maximum of six members per household annually. Community members who were neither CHF nor National Health Insurance Fund (NHIF) members were offered health services through user fees, which is payable at the rate of 1000/= at the dispensary and 2000/= at the health centre level per head. Our analysis indicated that in almost all facilities, the number of enrolment was decreasing year after year (Table 7). In contrast, in Iramba District, the health facility committees and the boards were perceived to be very useful. First, almost all respondents reported that the CHSB, hospital governing committees and health centre and dispensary committees played a very important role in sensitising the community members to join the CHF scheme. Most often, sensitisations were carried out by the health centre and dispensary committee members during village meetings. The CHSB also occasionally visited the health facilities. Consequently, as Table 8 indicates, CHF enrolment in the study facilities increased significantly 3 years preceding this study. Second, in one health facility, almost all members of the committee reported that they had recently managed to discipline some health providers, thereby improving health provider–community relations. One respondent expressed it as follows: At this facility we had nurses who had very bad reputation to the patients and the community members. But we managed to discipline them accordingly. They were ultimately transferred to other places (IDI with HFGC member). Another important issue that was reported by almost all respondents was supervising the rehabilitation and construction of the health facilities. The most frequent reported issue was the rehabilitation of houses for the health workers, the renovation of the health facility buildings and the construction of modern toilets. This was supported by some incharges of the health facility. When asked what sort of issues the committee is proud of, the respondent remarked this way:

Table 7. Community Health Fund enrolment in the study facilities in Lindi district Facility name 1 2 3 4 5 6

Rutamba Health Centre Kitomanga Health Centre Kilangala Dispensary Mahumbika Dispensary Mchinga Dispensary Mnolela Dispensary


2009

2010

2011

2012

60 8 6 10 7 15

67 24 4 8 5 12

33 35 1 7 3 10

12 13 1 8 0 5


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Table 8. Community Health Fund enrolment in the study facilities in Iramba district Number of households Facility name 1 2 3 4 5 6

Ndago Health Centre Kinyangiri Health Centre Mampanta Dispensary Bomani Dispensary Misigiri Dispensary Ulemo Dispensary

2009

2010

2011

216 182 100 81 53 103

163 190 132 141 79 192

233 349 225 206 81 425

Frankly speaking, what we have achieved is the construction of a new toilet at the facility. The committee members tirelessly wrote letters to the district authorities to request the possibility of using the CHF funds for the construction of the toilet. Surely, we had in the past written many letters to the district but were not successful. But through efforts of the committee members, we have succeeded to get this new toilet (IDI with in-charge of a health facility). In two health facilities, the researchers managed to see new and modern toilets, which had been constructed using the CHF generated resources. Furthermore, in all health facilities, the respondents reported that they had managed to significantly improve sanitation at the health facility. In one facility, almost all respondents reported that sanitation at the health facility had improved greatly over the last 2 years. One respondent explicitly remarked this way: The first thing which we are proud of is the improvement of cleanliness at the facility. When we got into the committee, the situation was very bad. The committee managed to educate the communities, and since then, cleanliness at the facility and the surroundings has improved remarkably (IDI with HFGC member). Further analysis of the interviews and the minutes indicated that in this particular health facility, there had been problems related to sanitation. As a result, three health workers, including the incharge of the health facility, had been transferred to other places. Involvement of the health committees in planning and budgeting. The review of the district health planning guidelines indicated that the Ministry of Health and Social Welfare issued planning templates for health centres and the dispensaries in 2008 and required the health centres and the dispensaries to prepare their plans which, in turn, were to be incorporated into the district annual health plans. Similarly, the review of the Comprehensive Council Health Plans (CCHPs) and the analysis of the district-level interviews indicated that the planning and priority-setting processes began at the grassroots level through health committees. In Lindi District, the researchers managed to see a sample of the health centre and dispensary plans that had been submitted to the CHMT. However, it was not clear how these plans were incorporated into the CCHPs. In addition, the analysis revealed that once the process Copyright © 2015 John Wiley & Sons, Ltd.


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of preparing CCHP had been completed, there was no feedback given to the health facilities. This implies that the health committees did not know which of their priorities had been accepted and which ones had not been accommodated into the district annual health plan. Furthermore, interviews with the members of the health committees revealed that while the health centres and the dispensaries submitted their annual plans and budget estimates to the District Medical Officer’s (DMO) office, they seem to have been largely prepared by the health workers. Findings from both districts of the study indicate that the health committee members only met to discuss the day-to-day management of the health facility. The analysis of interviews further revealed that almost all members of the health committees who represented ordinary communities were unaware of the existence of the district annual health plans. Factors that facilitated/constrained the performance of the health facility committees and the boards In both study districts, the health facility committees and the boards were reported to be paid with incentives to compensate them for their time. In Lindi District, the chairpersons and secretaries of the health facility committees were reported to be paid 15 000/= per meeting, while other members were paid 10 000/=. The chairperson and secretary of the CHSB were paid 60 000/=, while other members of the board received 50 000/= a meeting. The sitting allowances for the health facility committees and the boards, who were incorporated in the annual district health plans, were paid through the Basket Fund. Further analysis of the interviews across all respondents revealed that sitting allowances were hardly paid or were paid very late and sometimes, it could be paid after three or four meetings (three to four quarters). Consequently, meetings were not held as required, and some members of the committees did not attend the meetings. Some respondents expressed it this way: Members are paid sitting allowances but not on time. We may submit minutes to the district officials but they are sometimes approved after four months. We cannot pay the members before the minutes are approved by the district officials (IDI with an in-charge of a health facility). We normally hold meetings quarterly. However, it seems like the members of the committee are demoralised because we have not been paid sitting allowance for several meetings. We wrote a letter to the District Commissioner on this matter. We also summoned the District Medical Officer (DMO). He told us to be patient while payments are being processed. A few months ago we went again to the DMO and he told us the same story. This is a disturbance (IDI with HFGC member). In contrast, in Iramba, the district council had in essence managed to ensure that the health facility committee members were paid incentives on time. The chairperson and secretary of the committee were paid 3000/=, while other members were paid 2000/= after every meeting. However, there were concerns among all health facility Copyright © 2015 John Wiley & Sons, Ltd.



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committee members regarding the amount of incentives paid to the members. On the other hand, the members of the CHSB were relatively well compensated. The chairperson and the secretary were paid 70 000/=, while other members of the board received 60 000/= as their sitting allowance. In addition, members were refunded transport costs. In order to ensure that funds for the meeting were paid timely, the CHSB approved the use of the CHF and user fees and generated resources in general instead of the Basket Funds. In the past, the meetings were financed by funds from the Basket Fund. There were challenges because most often, the Basket Funds were untimely disbursed to the district. This largely affected the scheduling of the board and committee meetings. Second, in Iramba District, meetings were conducted monthly instead of quarterly as stipulated in the guideline for the establishment of the health facility committees and the boards. This made it possible for the committees to be aware of the performance and challenges of the health facilities. The records of the meetings were submitted to the CHMT on a monthly basis. From the first to sixth date of every month, the CHMT used to receive various reports from the health facilities, along with the minutes of the meetings. In these reports and minutes, various issues pertaining to the performance of the health facilities were documented. The DMO’s office provided travelling allowance for health workers who submitted reports. Almost all incharges of the health facilities viewed this as an incentive that motivated them to submit the reports and the meeting minutes on time. Furthermore, in Iramba District, the records of the meetings were available in all health facilities, which the researchers visited. There was some uniformity in the way the agenda of the meetings were presented. Issues that were commonly discussed in the meetings were as follows: the monthly collections from the CHF, NHIF and user fees; the performance of the health facility in terms of the number of patients attending the facility (children under 5 years old, pregnant mothers and elders above 60 years old); the number of exemptions for different groups of people such as the elderly, pregnant women and children under 5 years old; the status of medicine and medical supplies; and finally any other business. Furthermore, in almost all facilities, the list of the members of the health facility committee and the dates for the monthly meetings of the committee were available on the notice boards inside the office of the incharge of the health facility. Third, in order to improve the performance of the CHSB, the Iramba District council decided to widen the scope of membership. The District Health Secretary and the CHF coordinator were included as permanent co-opted members of the CHSB. These two members were added because of their central role in the management of the district health system. In the first place, the CHSB plays the central role in the management of the CHF. Thus, by co-opting the CHF coordinator, the board was frequently updated on the performance and challenges of the CHF, thereby taking prompt actions. Similarly, the inclusion of the District Health Secretary into the board meetings facilitated effective documentation of issues raised during board meetings, producing high quality minutes of the board meetings. This was possible because the District Health Secretary has been trained, among other things, to take records and minutes of the meetings. Similarly, the ward councillors were included as permanent members in the health centre governing committees. The Village Copyright © 2015 John Wiley & Sons, Ltd.


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Executive Officers were often invited to attend the dispensary health committee meetings. These made it easy for the issues that needed support from the village and the ward governments to be implemented promptly. Fourth, all health facilities in the district had the facility bank account primarily used to manage reimbursements from the NHIF. However, the district council also returned 20% of user fees and CHF to the facilities on a monthly basis. These funds were managed by health facility governing committees and were used in managing the day-to-day activities at the facility, including purchasing of drugs and other medical supplies and minor refurbishment of the health facilities. Notwithstanding these achievements, in both study districts, a number of constraining factors were reported. The fundamental problem that affected all health centres and the dispensary committees was inadequate training that is provided to the health facility committee members. In both study districts, health centre and dispensary committee members reported that 1-day training was provided during the inauguration of the committees and the boards. Likewise, 15 respondents (43%) in Lindi District reported that they had attended a training conducted at Mchinga ward in Lindi. The training lasted for 1 day and was provided by the DMO. In addition, the chairperson and secretary of the committees were also provided with training by the Tanzania German Programme to Support Health. However, 17 respondents (53%) reported that they had never attended any training on health facility committees. Similarly, in Iramba District, 20 respondents (40%) said that they had attended training on health facility committees and boards. On the other hand, 31 respondents (60%) reported that they had never attended any training. When asked how they learned their roles and responsibilities, the common response was that they were informed by the incharge of the health facility.

DISCUSSION This study on which this paper is based aimed at describing the differences in practice of the health facility committees in a well-functioning district and the one that committees are not that effective. The findings indicate that in both districts of the study, the health committees were in place. There is evidence to show that there was already some commitment from the central government to devolve power, authority and accountability to the districts and grassroots. That is, why committees were formed. It is evident from the analysis that in Iramba District, the committees and the board were performing better than in Lindi district. While very few success storeys were reported in Lindi District, in Iramba District, the CHSB, the hospital governing committee and the health centre and dispensary committees were perceived to be useful in sensitising community members on CHFs, supervising construction and rehabilitation of the health facilities, managing health facility bank accounts and monitoring the provision of health services at the facility, including drugs and medical supplies. Other achievements were tackling issues related to community–provider relations and sanitation at the health facility. Copyright © 2015 John Wiley & Sons, Ltd.



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Our analysis suggests that financial incentive to the health facility committees and to the board members was the main factor that facilitated good performance of the committees in Iramba District. Directly linked to this, the availability of financial resources at the facility level played a crucial role in enabling the committee members to meet, plan and implement their activities, increasing their sense of ownership and motivation. This finding supports a study carried out in Kenya, which underlined the importance of financial incentives for smooth functioning of health facility committees. The study found out that the breadth and depth of engagement of health facility committees increased after the introduction of direct funding of health facilities, which allowed health facility committees to manage their own budgets (Goodman et al., 2011). The study also found out that the availability of money for paying as allowances for committee members upon attending meetings increased participation and made the committee more viable, although members continued to see their role as largely voluntary (cf. Goodman et al., 2011). On the contrary, the findings of the study indicated that limited incentives, particularly for the health facility governing committees, adversely affected the smooth functioning of the committees and the boards. This problem seems to be perceptible in most districts in Tanzania as revealed in different studies (see, for example, Mubyazi and Hutton, 2003; Mubyazi et al., 2007; Kessy, 2008; Maluka et al., 2011). Furthermore, the managerial practices of CHMT and board members, including effective supervision and commitments of the district health management teams, were the important factors determining effective performance of health facility committees and boards. It was observed that Iramba District had implemented several innovative programmes that enhanced the performance of the health facility committees and the boards. Some indicators of effective performance included conducting meeting monthly instead of quarterly as required legally, paying incentives to the committee members on time from locally generated funds and establishing effective monitoring and reporting mechanisms. Local-level variations in the range of choice local officials made in the face of a common set of official rules may be important drivers in the differences in the activities, implementation and impact on health systems and outcomes that can arise under decentralization. Various studies support this (Bossert, 1998; Bossert and Beauvais, 2002; Bossert et al., 2007). According to Bossert (1998), decentralisation provides a range of effective choices to be utilised by local government authorities. The district-level and local-level officials who are allowed wider discretion may choose not to take advantage of the new powers and may instead simply continue to pursue activities as they had been doing before. Alternatively, they may choose to innovate new ways of doing things by making the choices they had not made before, thereby influencing the implementation of policies/programmes either positively or negatively (Bossert, 1998). While it is important to acknowledge health committees’ current contribution to improving access to health services through assisting clinic staff in their day-today operational tasks, assisting patients with health and social issues, running campaigns and informing communities about health issues, it is equally important to stress that this contribution is limited. The findings of the study imply that in many instances, the involvement of health committees does not meet the basic principles of meaningful participation such as being part of decision-making processes and having Copyright © 2015 John Wiley & Sons, Ltd.


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a governance or oversight function. Rather, health committees are primarily involved to a limited degree, for example, by assisting and supporting clinics in day-to-day operational tasks and providing assistance to patients. In these roles, they have marginal input in decision-making processes, overall health strategy, setting the agenda or identifying health needs and suggesting solutions. Limited involvement in decision-making could be attributed to the lack of clarity of the roles and the limited capacity of the health committee members. The lack of clarity in roles and responsibilities has been shown to be an important challenge in other settings (Loewenson et al., 2004; Kessy, 2008; Goodman et al., 2011). Previous studies have reported that the lack of clarity on roles can have significant negative implications for the relationship between health facility committees and the incharges of health facilities and/or health workers (Jacobs et al., 2007; Goodman et al., 2011). For example, in Kenya, the lack of clarity created tensions between committee members and facility staff, with lengthy debates among committee members about the extent of their autonomy in some areas (Goodman et al., 2011). There is a need of providing adequate training to the committee and board members. The training should cover the following aspects: roles and functions of the health facility committees and the boards; interaction between the committees, the communities and the health workers; development of health plans and budgets at the local and district level; and monitoring and tracking budgets. Methodologically, this study relied primarily on the review of minutes, site visits and key informant interviews with the community representatives and the district health managers. It is possible that the participants were shaped by social desirability bias and they might have told the researchers what the latter wanted to hear. However, no obvious inconsistencies were found between the interview data, the minutes of the meetings and the field notes, suggesting that what the participants were saying was in line with what was actually happening in the district. Additionally, the study did not adequately assess the demographic characteristics of the district health managers, management education and training, and management practices as well as the overall district specific contexts. Performance of the district health managers may relate, in part, to the calibre of managers, the work environment, the management support systems available and other district-specific factors. It is our hope that the study has shed some light on what the health facility committees and the boards actually do or what results they achieve. The study, therefore, would help the healthcare analysts, the decision-makers and others improve their understanding about the extent to which health committees in Tanzania fulfil their roles and why some functions are better than others.

CONCLUSION This paper has focused its attention on exploring the extent to which health committees in Tanzania fulfil their roles and why some are functional while others are not. It is evident that the health committees were important in assisting the day-to-day running of clinics. Managerial and leadership practices of the district health managers, including effective supervision and personal initiatives of the Copyright © 2015 John Wiley & Sons, Ltd.



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top district health officials coupled with incentives, are the major factors for smooth functioning of the health facility committees and the boards. Inadequate training and low public awareness were found out to have affected the performance of the committees. However, the findings demonstrated that community health committees were engaged predominantly in activities with limited influence from outside. No health committee was reported to be involved in influencing policy or in drawing up district health plans and budgets. A greater role in governance and oversight is essential for effective and meaningful health committee performance. To achieve impact, health committees will require adequate training on the following: roles and functions of the health facility committees and the boards, interaction between the committees and the communities and the health workers, development of health plans and budgets at the local and district levels and monitoring and tracking budgets.

ACKNOWLEDGEMENTS This study was funded by the Policy Research for Development, formerly called Research on Poverty Alleviation. We are very grateful for the financial support we received. We are also grateful to the local government officials, the district health authorities and other stakeholders in the study districts for their willingness to participate in the study. Furthermore, we are thankful to our research assistants for assisting us in data collection and analysis. The authors have no competing interests.

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