ON GOING RUNGWE PBF PROJECT TRAINING IN SWAHILI ''BUILDING CRITICAL MASS FOR PBF MOVEMENT IN TANZANIA''

On 12^th September 2011, the second year training for Rungwe Performance Based Financing (PBF) Pilot project started at Romanc Catholic church Youth Centre based in Tukuyu. The training will be ten days, from 12^th Sept to 22^nd September 2011. The training is being facilitated by KCMC team, Zonal PBF Coordinator and one facilitator from Igogwe Hospital. The training objectives are enable participants: firstly, to provide participants with an understanding of the relationships between national policies, health policy and economic policies and how they are influenced by Performance Based Financing. Secondly to understand the objectives, theories, best practices and instruments of Performance Base Financing and thirdly  to provide participants with knowledge and skills to enable them to improve the implementation of PBF in their work place.

What make this training peculiar is that it is mainly conducted in Swahili language, unlike last year which was in English and Swahili.

There are 20 participants, 14 are from Faith Based organization (FBOs) health facilities and 6 are from government owned health facilities.

The training was officially opened by the District Medical Officer (DMO), Rungwe District – Dr. N. Sungwa.  In his opening speech, he thanked the KCMC team for coming all way to conducting PBF Training in Rungwe.  Again, he thanked the participants for the response to attend this important course.  The DMO expressed that PBF pilot project is promising, but its implementation is tricky as basic prerequisite are not in place, referring to the policies which either need to be changed or adapt new ones.  However, he argued participants to study hard as the course is important for widening their scope on new health financing and for institutions they represent to effect change.  Additionally, he pointed out efforts done by the district, which include adopting some PBF principles, to start with they have set target to reach on Vaccination and Outreach; whereby if the staff reach target of over 80% they will be paid some kind of bonus.

Importantly, he noted the efforts to sign service agreement between Itete and Igogwe Hospitals with Rungwe District Council next month on maternal and neonatal Child health and under five years.

The DMO further said that, he expect to see the performance of health facilities whose staff  are taking part in this training to increase in terms of service coverage such as vaccination coverage, institutional delivery, and drugs supply. He, challenged the trainees to be change agents when they go back to their facilities. Finally Dr. Manongi, the PBF Training Coordinator from KCMC, thanked the DMO for the motivating and a well articulated opening speech.

See the Group Photo for PBF Trainees and  Trainers with Guest of Honour after Course opening.

Seated in front of participants: Second from right is the DMO Rungwe,

and followed by PBF Training Coordinator from KCMC- Dr. Manongi and

the Chairperson for the course on the left side. First from the right is the course

 participant.

National Health Costing Study Training

MOHSW in collaboration with CSSC conducted one week training on National Health Costing Study which was held Dar-Es-salaam at GIZ conference room at National Insurance Investment House from 25^th to 29^th July 2011.  The trainees were from: CSSC, MOHSW, and NIHF. Moreover, the training was facilitated by OPM (Oxford Policy Management) team. The study is financed by two organizations namely: GIZ and USAID.

The objective of the study is to provide MOHSW with cost information on RCH, Communicable and non- Communicable diseases.  Thus, MOHSW is expected to use the data to:

      To develop realistic estimates for over-all costs for prices setting on health sector

      Financial planning on medical care: short term, medium and long term

      Improve management of health facilities in terms of pricing/ cost sharing schedules

Stakeholders involved in the Costing study:

There are many stakeholders involved in this exercise.  They are basically categorized into three main groups: The financing agents in this case are GIZ and USAID. Those involved in health care include: MOHSW, NHIF, CSSC, APHFTA, NSSF/ SHIB.  The technical Consultants are OPM and Abt Associates inc.

In terms of roles: CSSC is responsible for the pre-test of the instruments, Pilot test, and conduct the collection in 154 health facilities in 5 zones covering all regions of Tanzania Mainland. On the other hand, OPM was engaged on developing the Instruments, Training the team from CSSC, MOHSW, NIHF and APHFTA. It will also carry out the analysis of the data after data collection from all five zones.  Moreover, Abt Associates Inc. will be responsible for quality control of the instruments during the study.

Coverage:

The study will be done in five clusters:  Cluster 1-Shinyanga, Cluster 2-Mbeya, Cluster 3- Iringa, Cluster 4-Kilimanjaro and Cluster 5- Dar- Es-salaam cluster,covering  27 Districts with a total of 154 health facilities both Public, FBO and Private.  Additionally, CSSC is taking the Lead for the data collection, whereby Mr. Runge is the Project Manager and Ms. Mecky Isasi is the Project Coordinator.

See the Photo of the participant during training Proceeding:

PBF Team meeting with CHMTs and HMTs members on 7th June 2011

On 7^th June 2011, PBF Rungwe Pilot Project team had meeting with Council i.e. Rungwe District) Health Management Team (CHMT) and Tukuyu Hospital Management Team ( HMT) members at DMO mini conference room for 2 hours, whereas a total of 19 members participated in the meeting.

The objective of the meeting was share PBF Rungwe Pilot Project information and advocate for PBF project principles adaptation in Rungwe District- especially in the health Department.  The meeting was opened by DMO Rungwe- Dr. Sungwa Ndagabwene.

Zonal PBF Coordinator- Mr. Sule, T.Michael made a brief presentation on PBF: which contained information on CSSC, PBF Multi-country network, Project objectives, expected results, PBF principles, project progress, challenges and proposed solutions.

After the presentation, the participants came up with questions and comments,  some of which   included the following:

-   What does Government say about motivating the staff?, as staff motivation is the key to performance of the health care.

-         The project is almost half of its implementation period, what can be expressed as success of PBF in the District?

-         How can staff be motivated fairly without bias, as bias can demotivate the staff badly

-         Comment: The members were argued to have mind set change in regard to performance, as for accountability.  As leaders we are supposed to help the staff to have their rights.

The raised questions were answered accordingly by Zonal PBF Coordinator and thanked the participants for their active participation in the meeting and argued them to think over some PBF principles which they could start with in the hospital.

However, the DMO Rungwe thank the PBF Team for the presentation and said that this give them a challenge on how to improve health care provision from input to output based financing.  He noted that they will discuss ways to adapt some PBF elements in the hospital management. 

From the above information, it is apparent that change is a process and will take some time, however, when the key leaders have the right information it is quite easy to accept the change in their work place

ITV Broadcasted National PBF Forum held in Tukuyu 4th March 2011

ITV Broadcasted National PBF Forum held in Tukuyu on 4th March 2011, on 11th March 2011- Under the period Called ''Events from here and there in Tanzania''

Second District PBF Forum held on 30th May 2011

PBF Rungwe Pilot Project organized quite successfully the second District PBF forum.  It was held at Tukuyu RC youth Hostel on 30^th May 2011.  The first one was held last year in August.  The objective of the forum was to update forum members on PBF Rungwe Pilot Project progress and to give feedback on challenges faced by Igogwe and Itete hospitals in CCHP plans preparation as part of Service Agreement arrangement.  The forum was opened by Rev. Geoffrey Mwakihaba – ELCT Konde Diocese Assistant to Bishop, and attended by 14 members.

Two presentations were made during the forum:  The first one was on PBF Rungwe Pilot Project Progress, challenges and proposed solutions by Zonal PBF Coordinator. On the other hand, the second presentation was made by Dr. Carina Dinkel from Itete hospital on Comprehensive Council Health Plan (CCHP)-the experience of Igogwe and Itete hospital.

After the presentations, the participants raised questions which were quite objective.  For example:  They were concern on: How can the Project help on Staff motivation, Is service Agreement understood well by Policy makers and implementers, Is SA worth striving for when it was realized that the Government has no fund to finance Service Agreement (Referring to Local Government as highlighted by DMOO), that District Council has no fund for Service Agreement and that Church leaders should  consult higher level Government Officials so that Service Agreement is given Vote in Government Budget.  Additionally, DMO commented that Policy making and implementation are two different things.  SA arrangement is a policy issue which need Political Commitment in order to have funds to finance it.

On CCHP Plan, Igogwe and Itete hospital experience.  Dr Carina indicated the difficulty faced by hospitals, and made reference to the guideline, which state that: The CDH and VA hospitals receiving Basket Funds or sign the Service Agreement are restricted not to charge MNCH services .Page 44, Point 3.2 e)  again, As the CCHP guideline was distributed as draft and there are also passages like: “CDH and VAH will receive funds from the Health Basket. The Health Block Grant will not be given to CDH and VAH because they receive their allocation directly from the central government (Service Agreement)“ 3.5, c), d), e) CCHP draft.

On this topic, that was a point of very active discussion.  The DMO intervened by saying that:  The CCHP Guideline used was a draft in the first place, though it was used for preparation of 2011/2012 Plans.  He noted that there were many things which were not so clear in the document.

The members were of the opinion that, CCHP Guideline need to give explicit clarification on how VAH will proceed on accessing government funding in health care provision.

After many hours of discussion and brainstorming on way out for Service Agreement, the forum members came up with one major recommendation which was: request Bishops to consult higher level Government official- they name Head of State to enable church facilities to have special vote in the Government budget for Human Resource for Health and Medical Supplies.  This request will be channeled through CSSC Zonal office.  With Such conditions in place, Service Agreement was said practical and feasible.

This was the most fruitful forum, which bring in board all key stakeholders who had open mind and sought after solutions for the project instead of pointing fingers on other parties, that is why it was aforementioned as very successful forum.

See the Group Photo of the Forum Members after the session.

                Seated in front from left-DMO Rungwe, next Chairperson of the forum

          and on the right, Chairperson of Moravian Church of Tanzania- South Province.

PBF Team Visit to Dioceses and Hospitals in Southern Zone

PBF Rungwe Pilot Project team and CSSC Zonal Secretary made a visit to three churches and four hospitals in Southern Zone for one week- from 22^nd to 27^th May 2011.  The aim of the visit was: to advocate and share information on PBF Rungwe Pilot Project  to church leaders and hospitals in Southern Zone of the CSSC.

The team started with Tunduru – Masasi RC Diocese and Met with the Bishop and discussed with him PBF project and its benefit towards health care provision.   The Bishop was quite positive towards the project concept.

 Later, we met the management team of Mbesa Hospital which is under the Christian Mission in Many Lands (CMML), the hospital is in Tunduru District and has 120 beds, 113 staff out of which 4 are doctors who are expatriates. PBF team presented the concept, which was appreciated by the team, who question it application in an environment whereby it is difficult to sign Service Agreement with local Government.  It was explained that this was a process which we need to keep on with plus contacting right people to influence policies.  The management team explained that, their staffs have 2 years contracts.  Above that, they give certain amount of money for hard working staff as part of motivation.  They were advised to apply the PBF principles in motivating the staff which are clear and transparent for all the staff.

Moreover, we had the chance to meet management of Nyangao hospital in Lindi, which had CDH status since 2009.  The PBF Team presented the PBF concept to the team and hence had  discussion.  Through the discussion, It was noted that hospital is doing quite well and has reasonable staffing level.

 On the other hand meeting with ELCT Iringa Diocese officials was quite a success.  We presented the concept, the officials understood  and accepted it.  They indicated that through PBF it is definite to improve performance in workplace and thus make their facilities competitive.

Additionally, we meet with Officials of the Moravian Church of Tanzania- South West Province, whose office is based in Mbeya.  Here the team liked the idea and had questions related to issues on motivation.  However, the later confirmed that this approach could also be applied in other sectors such as education as some of successful private schools do in the area.

We had a good discussion with Ifisi hospital management team which is under Evangelistic Church of Mbalizi and located in Mbeya Rural District of Mbeya Region.  Generally, the management raised many issues such as: how PBF can work in CDH environment, the motivation package, impact of project etc.  The team discussed with management team about the issues raised and they promised that they will study how to apply some of the key parameters of PBF in their hospital management.

Lastly, we visited Mbozi Mission hospital in Mbozi District of Mbeya Region. This is one of the famous hospital in the region as it was opened as a hospital back in 1961.  Again, the management raised interesting questions related to the project and stressed on sustainability of the project which were accordingly answered through discussion. 

From the Visit made it was noted that:  the church leaders are ready to support this health care financing model which is result oriented.  On the side of the management team, they considered that the hospitals can apply this approach when they have reliable source of funding such as stable Service Agreement with Local Governments. 

April 2011 Supportive Supervision

In this quarter the supportive supervision was done in 11 health facilities out of 12 health facilities planned.  The exercise took a total of 5 days.

As planned, the supportive supervision aimed at making follow up of issues raised as performance indicators in the health facilities.

In most of these facilities, Zonal PBF Coordinator either met the management of the health facilities or in charge of the health facility plus the assistant, which was common for the Dispensary level.

 From the general assessment, it was noted that there has been an improvement in the health facilities in the areas of record keeping.  It was manifested by better keeping of vital records at the facility level, which included: Reports, patient’s records, and general filling system which was formerly in very poor shape especially dispensaries.

Moreover, ledgers for medical supplies were found well recorded.  Again, information on HMIS was recoded and reports i.e. quarterly reports submitted to the DMO as required. 

Additionally, it was noted that most health facilities Facility Governing Committees for are meeting, though some dispensaries found it difficult to call these meetings on quarterly basis as a result of financial constraints.

On the other hand, the management meeting active for hospitals, but for Dispensaries and health centres there is no formal meeting neither minutes as they say they meet and discuss issues which crop up but not formalized.  No minute was seen from Dispensary and Health centre.  However, they were advised to have these important meeting and document issues discussed.

The issue of staff turn over was extensively discussed.  It was noted that hospital and health centres are currently hit hard by this situation.

Moreover, Institutional deliveries are still quite low in many health facilities.  Probably the trend will change at the hospital level as the hospital are instructed by DMO to have free services for pregnant women and under five children as per CCHP Guideline.  Again, the big challenge was noted on the Post natal Care, which was affiliated with traditions and culture in most cases.

Therefore, it is anticipated that the supportive supervision will improve the capacity of health facilities in ensuring performance of the day to day activities and thus contribute towards better health care provision.