For health providers like Justin Mayumba, a registered nurse employed at a health centre in rural Tanzania, working conditions have improved since the Tanzanian government rolled out a groundbreaking results-based financing (RBF) scheme to improve health outcomes in 2015. ‘This is a very good programme because it has facilitated the improvement of the infrastructure of the centre,’ Mayumba says. Operating in better-equipped facilities, doctors and health workers can deliver superior patient care.
Tanzania has reduced its child mortality rate, but the country still faces significant health and nutrition challenges. Malnutrition continues to prevent many children from growing to their full potential. In 2015, more than a third of children under 5, or 2.7 million children, were stunted. In the five years prior to the launch of this initiative, the maternal mortality rate actually increased from 454 to 556 per 100,000 live births, according to the country’s demographic survey. With two-thirds of Tanzania’s population of 55 million living in rural areas, delivering quality health and nutrition services throughout the country remains a challenge.
Currently run at facility level in eight of Tanzania’s 26 regions, the RBF programme is part of the broader Primary Health Care for Results, a $306 million programme that supports the Government of Tanzania’s Health Sector Strategic Plan IV at national and local government level. Funding from the World Bank, USAID, The Power of Nutrition, and the Global Financing Facility (GFF) backs this innovative scheme.
Participating dispensaries, local health centres, and hospitals had to meet minimum quality and infrastructure standards to join the RBF scheme, which financially rewards health workers and facilities for reaching a series of qualitative and quantitative targets. Local authorities monitor progress on a quarterly basis at facility level to assess patient care performance and quality before disbursing funds.
Performing regular ante- and post-natal checks on mothers, providing malaria treatment during pregnancy and offering family planning services, administering micronutrient supplementation for children, monitoring young children’s weight to spot early signs of undernutrition, and delivering targeted nutrition education are among indicators tracked by the programme. Facilities have autonomy to spend the grants they receive to repair buildings, buy medical equipment or drugs, or other initiatives according to their own prioritized needs. A 25% share of the facility-level funding is allocated to reward health workers.
Much work remains to be done to further improve health care in rural Tanzania, but surveys show that RBF, due to expand to other regions of Tanzania, is already producing positive results. ‘It has increased the morale, the motivation,’ says Dr. Ntuli Kapologwe, director for Health, Nutrition and Social Welfare services, President’s Office, Regional Administration and Local Government. ‘Now you can go to the facilities, you find the health service providers are enthusiastic, they are quite happy.’ The new scheme has also encouraged health providers to view patients more as clients they have to attract with good services.
The RBF scheme has also led to measurable advances in many rural districts of Tanzania, where health facilities often lacked adequate sanitation, and faced staff, equipment, and drug shortages. In the eight regions covered by the scheme, 16 out of 18 quality indicators at dispensaries and health centres have improved. Average hygiene and sanitation quality scores, for instance, rose from 54% to 92% between April-June 2016 and July-September 2017. For women giving birth, the quality of services during labour and delivery improved markedly between 2016 and 2017, rising from 57% to 90% during a 15-month period. Thanks to the results-based programme, ‘When our stocks of drugs are diminished, we go and purchase them,’ says Petro Charles of Ng’wandu village dispensary. ‘Hence service delivery is improved.’
In many rural villages, community health workers (CHWs) are volunteers. Now, funding is available to pay them for their work. Through home visits and regular contact with the community, CHWs can deliver crucial messages on issues of maternal health and child nutrition such as breastfeeding, children’s diet, and the importance of colostrum. A survey showed that 97% of health workers reported talking about child nutrition. Most of them also measured children’s weight, although only 42% measured their height. ‘Community Health Workers help us a lot because they are well trained and they help us with monitoring of mothers who are breastfeeding, pregnant mothers who are supposed to attend early sessions at the clinic,’ says Justin Mayumba. ‘The mothers who have to go to delivery, the CHWs escort them to the hospital.’
Patients, who were often frustrated by poor service at nearby health facilities in the past, have already noticed positive changes since the launch of the results-based programme and express satisfaction. Now that local health centres can address their health needs, community members no longer have to travel long distances to get adequate care. ‘In addition to the new worker who was hired, our children are getting good services; even we, parents, are getting good services,’ says Martha Shija, a mother from Ng’wandu village.
