Understanding stakeholders' roles in health sector reform process in Tanzania : the case of decentralizing the immunization programm

The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review,
in-depth interviews, key informants interviews and observations. Quantitative
methods involved retrieval of secondary data, health facility survey and
household surveys. Regular discussions with key informants and data
collectors were held to verify the findings. Qualitative data was analysed
manually. Quantitative data was captured and analysed using Epi Info version
6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do
reforms learn from history? Analysis of the waves of health reforms prior to
the current reforms from 1926 was done to answer the question. The main
stakeholders in the reforms were the political party in power, the government
and donors who supported the reforms each time. Each wave of health sector
reforms provided information on health provision, financing and resource
generation. Due to the political contexts, information on failures of health
financing did not provide lessons for succeeding reforms of the health sector.
Stakeholders’ political interests opposed lessons that did not match the
political ideology at the time i.e. free public services versus privatization and
paying for social services. Lessons from previous health reforms were
selective, and did not consider health-financing needs among others. The
ongoing health reforms needed to use information from all functional aspects
of the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health
reforms and what were their interests and reactions? The main stakeholders
were donors, and the government. The two had a very high support for the
reforms evidenced by their participation in problem identification, justification,
reform design, planning and implementation. The health sector reforms thus
had high political support at central level. In the implementation process,
issues that triggered stakeholders’ reaction included sectoral versus local
government decentralization. Another issue was the donor modality in
financing the health sector and need for adopting new financial management
systems. Among the donors there was hesitancy to join the common financing
modalities that included a Sector Wide Approach (SWAp) and Basket
Funding. As a result, there was delay in the process in order to reach better
consensus.
The third question was: What was the impact of stakeholders in the process of
reforming a vertical programme like EPI? Health Sector Reforms in EPI
included integration of generic functions, for example, vaccine procurement to
medical stores department. Qualitative and quantitative data was collected
and analysed from the Ministry of Health, EPI management unit. This again
revealed that EPI reforms were well supported by the government and donors
centrally. EPI managers at both district and regional levels opposed some of
the EPI reforms. They argued that coverage was falling due to the reforms.
However, there was no concrete evidence relating reforms in the EPI
programme and falling coverage. The primary aim of certain actors was to
make sure that they continued receiving extra income from EPI functions. One
of the effects of stakeholders’ reaction was reversal of reforms (recentralization)
and return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to
decentralization at district level and how might it have affected performance of
EPI functions and the challenges? The immediate reaction of stakeholders
was reduced cooperation between the Council Health Management Team
(CHMT) and the District Council who were politically supreme in the district.
Within the Council Health Management Team there was inadequate
communication, which led to poor teamwork. The result of this was reduced
supervisory visits to peripheral health facilities. The EPI coverage in the study
district was 52.8 per cent, which was well below the previous national average
(80 per cent). A logistic regression model for EPI service quality variables on
children between 12 months and 23 months who had completed vaccination
was applied. Certain EPI quality of service variables predicted significant
changes in the odds ratio for completing vaccination. It was then suggested
that strategies were needed to improve management skills among the CHMT
and District Council members. Also there was a need of hastening the
process of increasing remuneration and motivation of peripheral health
workers. The fifth and final question was: What was the interest of the stakeholders
and prospects of increasing EPI coverage at district level? Decentralization
and integration of EPI functions were among the reforms at district level. The
analysis revealed that active stakeholders at district level were the Ministry of
Health, CHMT, EPI managers at district and regional levels and facility
providers. The Ministry of Health opposed integration of EPI at district level by
issuing the directive that DCCOs and MCHCOs (EPI manager at district level)
should resume their tasks. However, the CHMT had no option but to comply.
This action reversed some of the health reforms at district level. Analysis of
the importance the community attached to EPI, using willingness to pay for
EPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI
service quality variables were significantly negatively associated with odds
ratio for willingness to pay for EPI input. Simulation with Policy Maker
computer software predicted that an increased number of stakeholders
through community participation would significantly improve the current low
level of EPI coverage. It was then proposed to do a similar analysis in other
vertical programmes and implement on a trial basis the results of the
simulation.
In conclusion, stakeholders were found to be active and influential in the
health sectors of developing countries like Tanzania but poorly considered in
implementation of reforms. Stakeholders are important since some strongly
support while others oppose the reforms. The reaction of stakeholders is
evident through deployment or non-deployment of information depending on
interest and context. This would result in poor management leading to
inefficiency in resource use, which would then be followed by poor quality of
services, poor support by communities and consequently poor utilization of
health services. It is suggested that stakeholder analysis be conducted in
other vertical programmes in the process of integration. Promotion of
stakeholder analysis and also Policy Maker as a tool to manage stakeholders
will facilitate the management of reforms in the health sector.