Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania

Abstract

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral facilities in low-income settings. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used as it allows in-depth, multi-faceted explorations of complex issues in their real-life settings. Three district councils were purposively sampled: one urban and two rural districts councils. Two rounds of data collection were carried out in 2013 and 2015 to understand the initial implementation steps, the stakeholders involved, their expectations and implementation challenges at the district and facility level. A total of 34 focus group discussions and 14 in-depth interviews were conducted across the three districts, together with a document review. Thematic content analysis was used for data analysis. The study revealed that formal and informal communication from the district managers to the health facilities had been used in the process of facilitating the opening of facility bank accounts. The main use of bank account revenue was for the purchase of drugs, other medical supplies and minor facility needs. To ensure accountability for funds used, facilities had to submit monthly reports of expenditures incurred by the facility. District managers also undertook quality control of facility infrastructure which had been renovated using facility resources and purchases of equipment and other supplies. Facilities reported challenges in securing financial resources to cover transport costs, 3 stationary and the initial deposit funds when opening the accounts. Moreover, implementation did not take into account the preparation needed to empower facility staff and facility governing committees to effectively manage and report on funds deposited in their accounts. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery in peripheral areas. The experienced process of opening facility bank accounts, managing and using the funds; highlights the need to strengthen the capacity of staff and health governing committees.

The Direct Health Facility Financing Impact on Financial Management in Kaliua District Council, Tabora Tanzania

“…Under DHFF, funds were directly disbursed from Ministry of Finance and Planning (MoFP) to primary health facilities from financial year 2017/2018. This was done with a conception that DHFF would improve community participation, autonomy, efficiency and effectiveness of available resources and quality of care in sustainable manner (Policy Commitment, 2016;DHFF guide, 2017, Kuwawenaruwa et al, 2018Kapologwe, 2019).…”

“…In addressing the above problems like many other countries, Tanzania has gone through several health financing reforms such as Arusha declaration in 1967, which advocated for free health care for all, in 1991 the re-introduction of private health care provision was opted to complement the public sector; In 1993-2004 the introduction of user fees in public facilities to promote equity in accessing health services among the poor; in 1999, a National Health Insurance Fund (NHIF) for public sector workers and in 1996 a Community Health Fund (CHF) (Gemini et al, 2007;MoHSW, 2010;Kolstad & Lindkvist, 2013Mujinja & Kida, 2014. The generated and collected funds by health facilities from user fees, CHF/TIKA premiums, NHIF reimbursement used to be submitted to local government authorities (LGAs) whose vested with power to manage the provision of public services including health services at council level under Local Government Act (LGA Act) of 1982 (Boex, 2015;Kuwawenaruwa et al, 2018 ). In which councils were responsible to plan and control the utilization of fund on behalf health facilities.…”

Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation

“…Structural factors such as the lack of financial autonomy for primary care providers limited their ability to benefit from the additional resources generated by the scheme and to further invest them in quality improvements. The recent national roll out of bank accounts at primary care level in Tanzania will go some way to alleviating this problem and increasing the potential of the scheme to improve quality going forward (Kuwawenaruwa et al, 2018).…”

Acceptability of the Direct Health Facility Financing (DHFF) initiative in Tanzania: A mixed methods process evaluation of the moderating factors

“…This reform involved direct disbursement of mobilised funds from the Ministry of Finance and Planning (treasury) and other sources to primary health facility bank accounts. 10,15 The funds mobilised at the central level through external sources (such as health sector basket funds) and internal sources (such as government grants) were disbursed to the health facilities to meet operational requirements as stipulated in their budgets. This reform aimed to respond to delays in funding disbursements to primary health facilities observed in the traditional way of disbursing centrally generated funds to local govern-acceptability as programs are designed and implemented is the holy grail of acceptability of complex interventions.…”

“…Tanzania adopted a DHFF initiative in 2017 as part of the strategic purchasing of health services aimed to hasten achievement of UHC and advance health financing decentralisation reforms. This reform involved direct disbursement of mobilised funds from the Ministry of Finance and Planning (treasury) and other sources to primary health facility bank accounts 10,15 . The funds mobilised at the central level through external sources (such as health sector basket funds) and internal sources (such as government grants) were disbursed to the health facilities to meet operational requirements as stipulated in their budgets.…”