CHARACTERISTICS OF THE RESPONDENTS
The study interviewed 23 Respondents who were categorized into three categories; the first category include eight (8) district health managers, the second category include eight (8) facility health care workers the last group include seven (7) patients.
Table 1provides a summary of the demographic information of three groups who participated in the study.
The majorities (74%) of respondents were female and 83 % of respondents’ ages were above 40 years and 17% were below 40 years. The level of education of respondents varied between patients who had mostly primary and secondary education levels while the district Health managers and hospital care workers had college or university education level.
Table 1: Demographic characteristics of participants
Characteristics
|
District health managers
|
Facility HCWs
|
patients
|
|
Number (n=8)
|
%
|
Number
(n=8
|
%
|
Number
(n=7)
|
%
|
Sex
|
|
|
|
|
|
|
Male
|
3
|
37.5
|
1
|
12.5
|
2
|
28.57
|
Female
|
5
|
62.5
|
7
|
87.5
|
5
|
71.43
|
|
|
|
|
|
|
|
Age (years)
|
|
|
|
|
|
|
Below 40 years
|
0
|
0
|
2
|
25
|
2
|
28.57
|
Above 40
|
8
|
100
|
6
|
75
|
5
|
71.43
|
|
|
|
|
|
|
|
Level of education
|
|
|
|
|
|
|
Primary
|
0
|
0
|
0
|
0
|
5
|
66.67
|
Secondary
|
0
|
0
|
0
|
0
|
2
|
33.33
|
College/University
|
8
|
100
|
8
|
100
|
0
|
0
|
|
|
|
|
|
|
|
Working experience in years
|
|
|
|
|
|
|
Below 3
|
0
|
0
|
4
|
50
|
|
|
3 and Above
|
8
|
100
|
4
|
50
|
|
|
|
|
|
|
|
|
|
Occupation
|
|
|
|
|
|
|
Small vendors
|
|
|
|
|
4
|
57.14
|
Self employed
|
|
|
|
|
3
|
42.86
|
The results are presented in two main themes, the first theme is on the opportunities of implementing SA, which has eight sub themes, namely: presence of policies and guidelines for implementing SA, patients receiving services at reduced cost and some at free cost, presence of supportive supervision and workers involvement in trainings and mentorship, presence of SA review meetings, good PPP coordination, political support, trust of the hospital to suppliers and trust between the parties implementing SA. The second theme is on the challenges of implementing SA which has four sub-themes namely inadequate deployment of Human Resource for Health (HRH) by government to the hospital, inadequate fulfillment of government financial commitment to support the hospital, lack of transport for supervision and donor dependency.
The opportunities of implementing Service Agreement in the hospital
The participants were asked about the opportunities available for implementing SA as a tool to facilitate the public private partnership projects in the provision of health services in Ilala Municipality. Analysis of the findings generated eight sub-themes about the existing opportunities for implementing SA, namely: the existence of guidelines and policies, patients receive some health services free of charges, availability of some services in reduced prices, availability of supervision, training and mentorship opportunities, presence of good PPP coordination, presence of SA review meetings, existence of political support, trust of the hospital by suppliers and trust between government and the hospital.
Patients receive some health services free of charges
Interviewed patients and health workers at the hospital reported that there are number of health services that are currently provided free of charges. These include: weighing of children, assessment of children, provision of health education, vaccination services, Ant malaria (SP) also known as IPT, drugs for deworming, Ferrous and Folic Acid (FEFO), HIV test, opening of Cards and pregnancy assessment. All these services are provided at the Reproductive Child Health (RCH) clinic as one respondent said,
“When I came here while I was pregnant, a number of services were provided free. These included: health education, assessments of pregnancy, deworming drugs and many other services” (IDINo.04 female patient).
Patients receive some health services at reduced prices
Interviewed patients and health workers at the hospital reported that there are number of health services that are currently provided at the reduced prices. These include: test for hemoglobin and delivery services. For instance, delivery services are provided at reduced price of Tanzania’s’ Shilling 50,000/= instead of 100,000/= per one normal delivery. HB is charged at reduced price of 2000 instead of 4000. One of the respondents reported,
“During delivery I could not deliver normally so I undergone Hemoglobin check-up for 2000/= and then after that I delivered by cesarean section which costed only 100,000/= and it was cheap compared to other private facilities for the same services I got here” (IDI No.03.Female patient).
Existence of guidelines and policies on SA
The interviewed study participants reported that the implementation of SA is possible because it is enabled and facilitated by national policies and guidelines. For instance, they mentioned that the presence of SA implementation policies and guidelines clearly state all the procedures for implementing SA at council levels. One respondent said,
“We are able to implement Service Agreement without any obstacle because it is directed by national guidelines and policies and not from me as Municipal Medical Officer; if it could be my directives, then we could have failed” (KI NO. 15- CHMT).
Moreover the interviewed members of the hospital management team and health workers reported that the partners who implement SA are also obliged to observe government guidelines that provides directives on how various health services including RCH services should be provided:
“We have government guideline related to provision of RCH services here and we are obliged to follow it as per SA” (KINo.02HMT).
Health workers involvement in trainings
Training is one way of making sure that services are provided at the required standards. Health care services do undergo changes in line with technological advancement and recommendations from researches. Interviewed members of the hospital management team reported that after starting implementing SA the staff from the hospital are included into trainings and given updates of services provision by the CHMTs. Such trainings aim at ensuring that services are provided by skilled and updated health care workers. This was not the case before service agreement. This was remarked by one of the interviewed HMT members:
“We have seen Service Agreement to be beneficial to us because now days as the hospital leaders and workers are included in the trainings and given updates on changes regarding health services provision. This helps to motivate workers and improves the quality of services provided as agreed in the Contract” (KI No. 11HMT).
Supportive supervision and mentorships
Majority of interviewed District Health managers, members of the Hospital Management team and health care workers mentioned supportive supervision as an opportunity of implementing SA. Supportive supervision refers to a friendly and more supportive way of making something to happen in a right way as required where by supervisor and supervisee assumes the same role of teaching and learning from each other. This was also evidenced by researchers from the hospital visitors’ book whereby more than 17 Supportive Supervisions were recorded in the past twelve (12) months. Five supportive supervisions were conducted in each quarter (first, second and third) of financial year 2018/2019. Only two supportive supervisions were conducted in the fourth quarter of financial year 2018/2019. Furthermore, Respondents reported that Supportive supervisions and mentorships give opportunity for improving the quality of services provided. One of the respondents said:
“We are conducting supportive supervision quarterly but for us it is integrated supervision and not specific for SA. Most of the time it includes different departments such as RCH, Quality improvement, Laboratory services, Pharmacy, HIV and checking for HRH. It is very comprehensive which also includes the services agreed in SA” (KI NO. 16 CHMT).
Service Agreement review meetings
Majority of the interviewed respondents reported that SA implementation is also monitored by the SA review meetings which are done once per year between district government officials and the Hospital management. The review meetings are used as platform for both parties (Local Government Authority and Rugambwa Mission Hospital) to monitor and evaluate the progress of the implementation of SA activities as well as challenges and solutions of implementing SA. It was reported that SA review meetings give parties an opportunity to report the progress as well as challenges of implementing SA. For example, one respondent had this to say:
“We call Cardinal Rugambwa Management members for review meetings every year and we also have long review meeting when the contract ends whereby we as government party, we give feedback and informs them on some changes if any in the contract and they also get opportunity to give their opinions” (KI NO. 19- CHMT).
Trust of the hospital to suppliers
The interviewed study participants reported that the Mission hospital is trusted by suppliers of various drugs and other medical supplies because it is owned by the religious organization. Given such trust, the hospital can take equipment, drugs or medical supplies and promise to pay later. Such arrangement contributes to smooth running of the hospital activities including provision of services as agreed in the SA. The findings show that the hospital is run by religious congregation which put it at advantageous position to be trusted even by suppliers. One of the respondents said,
“We are church people and we are trusted outside (suppliers) there even if we have not received Health Basket Fund for that quarter then we just ask them to supply us with commodities worth even over 30 million and we promise them to pay when we get fund from the Council and most of them, say Sister just take it we are sure you will pay us. And when I get money, I pay them on time. This has helped us to provide services as agreed in Service Agreement even if funds have delayed” (KINo.09- HMT).
Trust between parties in SA
The interviewed district health managers reported that they trust the data and reports from the hospital and also the hospital trusts the government through Municipal Council Medical Office. They claimed that this type of trust is good for having productive partnership as elaborated by one of the respondents below:
“Now we trust them and they trust us very much and we trust even the reports they are submitting to us. This is now very strong even they dare to report the bad things happening such as maternal deaths. For instance last year Cardinal Rugambwa Mission Hospital reported two maternal deaths which were not the case before that because we told them that they will not be penalized when maternal deaths happen but when it happens we need to organize a joint meeting to find out the causes and put measures of ensuring that it does not happen again” (KINO. 18- CHMT).
Presence of good coordination
The interviewed study participants reported that the Municipal Council Medical Office has appointed a responsible person to coordinate all Private Health facilities in the council and is responsible for all matters related to SA as well as PPP in general. This was mentioned to be an opportunity in implementing SA in the council. One of the respondents expressed the following:
“The act of having PPP coordinator is also a factor which has helped us (the municipal council) and Cardinal Rugambwa Mission Hospital to implement well the SA because he acts also as a channel of communication between the council and Cardinal Rugambwa Mission Hospital and other development partners who have interest in SA and PPP in general. If we miss transport for supportive supervision he goes to APFHA and we are given a car to conduct supervision. He actually coordinates well everything related SA in the Council and that is why we are doing well with SA implementation” (KI NO. 18- CHMT).
Existence of Political support
Majority of the interviewed Municipal Health Managers, Council Health Services Board and members of the Hospital Management Team acknowledged that they get full political support in the implementation of SA. This was seen as a major opportunity because politicians such as councilors have an influential power in making decision regarding any project or activity, which is being implemented at Local Government Authorities level. In this aspect, one respondent had the following remarks:
“The councilor of this area of Ukonga was very positive in supporting SA while holding talks with the Local Government officials for signing this Service Agreement and he has being supporting its implementation and actually he is a member of Hospital governing Board. He is marketing and advocating the availability of our services to the citizens. He always asks about our services and if we face any challenge he is there to support us. For me I think he has remarkable contribution in successfully implementation of SA in Ilala” (KI No 11.HMT).
The challenges facing the implementation of SA in the hospital
The participants were asked about challenges affecting the implementation of SA in Ilala Municipality. Analysis of the findings generated four sub-themes as described below: inadequate deployment of health workers to the hospital, inadequate fulfillment of government financial support to the hospital, lack of transport facilities and donor dependency.
Inadequate deployment of health workers to the hospital by the government
The interviewed respondents acknowledged that as part of the SA, the government agreed to deploy seven staff including three nurses, two laboratory technicians and two clinicians so as to increase the number of services provided by the hospital as well as improving the quality of services. However, by the time of undertaking this study, the government deployed only three staff including two laboratory technicians and one (1) clinician. When commenting on the deployment of health workers, one respondent said:
“We agreed that the government will deploy seven health care workers to the hospital in these three years of implementing SA including two laboratory technicians, three nurses, two clinicians however till now which is the end of third year we have received only one clinician and two laboratory technicians”(KI No.11 HMT).
Inadequate fulfillment of the government’s financial commitment to support the hospital
According to SA between Ilala Municipal Council and the hospital, it was agreed the government has to send 10% of total Council Health Basket Fund received to CRMH for each quarter. However the exact amount was not agreed due to its fluctuation tendency. The interviewed members of the Hospital Management Team reported that delay of funds caused many problems such as lack of smooth continuation of services because sometime the hospital delay in procuring medical supplies, delaying in paying workers’ salaries and inadequate funds for administrative costs. One of the respondents said,
“The Health Basket Fund from the government is headache in the sense that it is not coming on time and quarterly as agreed but now it sometimes comes at the end of the quarter and sometimes we do not receive at all and when they send it, it comes two installments for two quarters, one for the current quarter and the other one for the previous quarter but they need to be retired immediately before the end of that quarter. Another thing is that we only know that we are supposed to get ten percent of the total Council Health Basket Fund but we do not know the exact amount since we do not know the total amount of basket funds for the council” (KI No.12HMT).
Lack of Transport for conducting supportive supervision
The interviewed study participants reported that the Ilala Municipal Council Medical Office has a big problem of transportation and this has affected the implementation of SA as the District Health Managers fail to go for supervision to the hospital. The health department has a few vehicles which are not enough to carry out regular supportive supervision to all health facilities including Rugambwa Mission hospital. One of the respondents had the following remarks,
“As I have said earlier on we have failed to go for supportive supervision because we have no transport for such visits as you know we have few vehicles and there are many ad hocks (emergencies) in this municipality. All these emergencies need transportation and you cannot control them” (KINO. 18- CHMT).
Donor dependency
The interviewed study participants especially at District level reported that the Municipal Council Medical Office depends on resources from Association of Private Health Facilities in Tanzania (APHFTA) and development partners through Basket Fund for the implementation of SA. Basket Fund is the main source of fund pooled from different development partners through the government channels and the fund is sent to LGAs for supporting health interventions in the council. The guidelines directs 10 -15% of the total Basket fund received by a council to be used in those voluntary agency facilities operating under SA. The development partners support the LGAs by providing them with transportation, trainings and funds for the implementation of SA. If such support decreases and many development partners withdraw as it is the case now or ceases to exist, then the implementation of SA will also stop. In support of this finding, one the respondent said,
“We understand that these funds are not ours we are just given by donors. We need to use them well but we would like to acknowledge the support given by APHFTA. Without this association maybe we could not have SA in Ilala. They were the first to convince us and to talk to Ilala Municipal Council on collaborating and signing SA. Till now they are calling us together and providing trainings on SA. If we have challenges related to implementation of SA we feel that APHFTA‘s office is our home” (KI NO. 01.HMT).