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FINANCIAL ACCOUNTABILITY IN RURAL PUBLIC HEALTH PROGRAMS: The Case of Maternal Health in Kigoma and Rukwa Regions

PhD Thesis Concept By

Respicius Shumbusho Damian +255 713 428 318/ +255 786 428 318

1. Problem Context and Overview Since independence, the government of the United Republic of Tanzania has carried out several initiatives to improve public health care for its citizens. Before 1991, health service delivery was mainly a state prerogative (Abdallah, 2002). Even few urban private owned facilities, were banned 17 years after independence under the Private Hospitals Regulation Act of 1977. All citizens directly received services from the government and thus accountability meant ensuring access of citizens to services. In the 1990s, as part of the public sector reforms, Tanzania amended the Private Hospital Regulatory Act allowing for provision of health services by the private facilities. In 1996, the government inaugurated the Health Sector Reform, which among other things emphasized improving the role of private sector in health services and community participation in financial planning, spending, and monitoring and evaluation of health services. Equally, the reform aimed at increasing financial sources and improving financial management to ensure effectiveness of services. To realize this objective, the government adopted strategies for ensuring sustainable health care financing, which involved both public and private funding as well as donor sources. Government commitment in implementing public health reforms since 2000s attracted more financing of public health programs by development partners including; African Development Bank (ADB), Canadian International Development Agency (CIDA), Clinton Foundation Tanzania, Embassy of Denmark (Danida), Irish Aid, UNICEF, UNAID, UNAFPA, World Bank, USAID, and World Health Organization (NIMRI, 2006, URT, 2008c). Due to such growing sources of fiscal space between 2000 and 2010, the general trend of government spending on public health care programs significantly increased from 9.1 percent of the total budget in 2000 to 13.7 percent in 2010 (URT, 2011). The implementation of the reform went side by side with development of health related policies and strategies such as the National Policy 2003 and its revised version of 2007, National Vision 2025, health sector strategic plans, and the National Strategy for Growth and Reduction of Poverty (NSGRP). All these policies and strategies emphasize prioritization and increased participation of communities in monitoring the use of financial resources to achieve effectiveness in health services (URT, 2003; URT, 2008c; URT, 2005). As one of the priority areas, Maternal Health Care (MHC) has received higher stakeholders’ commitment in terms of financing, campaigning for community participation, and influence on financial planning and cost effectiveness of services. This commitment is informed by altruistic philosophy that when a woman undertakes her biological role of becoming pregnant and undergoing childbirth (Mwaikambo, 2010), the society has an obligation to fulfill her basic human rights and that of her child, important of these rights being the right to live healthy life. In addition, there have been educational interventions by development partners and civil society actors to empower communities to participate in monitoring public health finances and cost effectiveness of services provided to them. This included training to local community leaders and representatives in local councils (De Graaf, 2005). Despite the efforts to ensure financial accountability in public health programs, it is identified that participation of communities in governing bodies at both health facilities and council levels is very not satisfactory (Kiria, 2009; SDC, 2012; Muhondwa, Nyamhanga, and Frugence, 2008; Mushi, Melyoki, and Sundet, 2005; Mwaikambo, 2010). In order to achieve effective implementation of community public health programs including MHC, about 40 percent of the health sector budget is directly managed at district level (Kiria, 2009). This implies taking financial decisions closer to the users that goes together with encouraging and enlightening communities to monitor and hold accountable both district authorities and service providers for proper planning and effective spending of finance (URT, 2008b). The reason behind prioritization of rural areas

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is that; the total fertility rate is high in rural areas compared to urban areas where between 2000 and 2010 it was 5.7 children per woman and above (Mwaikambo, 2010). Financial decentralization, which is a generic component of Decentralization by Devolution (D-by-D), is designed to make citizens including those who live in rural areas play their civic role, which is ensuring cost-effectiveness and quality of services provided to them (URT, 2008a). Accountability in general and financial accountability in public health care in particular, has revealed to be a crucial factor for achieving effectiveness in service delivery. It mediates between the government and citizens on issues of cost, quality, and access of services, it also controls corruption and bribery by health care services providers, and it regulates the excessiveness of powers of service providers over the users of services (Brinkerhoff, 2004). Financial accountability has two important dimensions; answerability, which means accounting for justification of actions and enforcement, which means the powers and mechanisms to sanction non-satisfactory actions and their justifications (Scheduler, 1999). Therefore, effective financial accountability requires that there exist mechanisms for making public authorities and service users answerable to the users of public health services and the users should be capable of holding the service providers and public authorities accountable for their actions and inactions in the allocation of financial resources and cost effectiveness in public services delivery. The necessity of the citizens, taxpayers to hold public health care services providers also comes in due to the fact that the finances that is allocated for public health care is the taxpayers’ money, and the health of a taxpayer is crucial for continuity of government revenue (Brinkerhoff, 2004; Cooksey and Kikula, 2005 ). 2. Problem Statement Since 1990s, there have been several efforts to enhance community role in ensuring financial accountability in health services delivery. These efforts have included having in place policies and laws that allow community actors to hold public authorities and service providers accountable for financial plans, decisions, and spending as well as educational interventions by development partners and civil society actors. Despite express legal guarantee and awareness creation interventions, the financial accountability role of community actors seem to be inadequate (URT, 2008b; URT, 2007; URT, 2008c). After almost a decade of substantive financial support, donors, and development partners who provide significant contribution for financing public health programs, acknowledge that Tanzania is not fairing well in terms of Public Expenditure Financial Accountability (PEFA). At the same time, they question why there is little propensity of communities to play their financial accountability role, which for them would depress the levels of aid from development partners (World Bank, 2011, Ministry of Finance, 2013). In addition, they acknowledge that the expected role of communities in enhancing cost effectiveness of services through financial accountability has not been realized. At the same time, official documents acknowledge that there is inadequate community involvement and participation in planning, implementation, monitoring, and evaluation of health services (URT, 2008c). The Public Expenditure Trucking Surveys of 1999 and 2001 revealed that about 67 percent of finances allocated for health facilities in rural areas did not reach their destinations (Kanungo, 2005). Both official and academic sources emphasize that community involvement is necessary for ensuring financial accountability, but little is known on whether there are efficacious mechanisms for communities to play their role in ensuring financial accountability in public health programs. The puzzle is therefore why the communities’ role in ensuring financial accountability is inadequate despite efforts by the government, development partners, and civil society actors to make sure that community actors are capable of holding authorities and service providers accountable in planning, allocation, and spending of funds? This is an important question to address since it is expected that responsible communities would strongly seek to monitor the planning, allocation, and spending of the financial resources that are aimed at ensuring that they receive quality services, especially sensitive services like maternal health care services. 3. Study Objectives

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The general study objective is to examine the role of community in rural public health financial accountability. Specific Objectives To accomplish the general objective, the study shall address three intertwined objectives as follows: • To identify actors, their powers and roles in rural public health financial accountability • To review the existing mechanisms (processes, structures, policies, and procedures) used by

community actors to ensure financial accountability. • To examine the capacity and influence of the community members in ensuring financial

accountability in rural public health programs. 4. Research Question What role do communities play in insuring financial accountability rural public health care programs? Specific Questions • To what extent the actors who are actors in rural public health programs having sufficient powers to

ensure financial accountability • What financial accountability mechanisms (policies, structures, and procedures) are in place to be

used by community actors? • To what extent are community members capable of ensuring financial accountability in rural public

health programs? 5. Data Sources and Methods Data required for this study is expected to be acquired from primary and secondary sources. Primary data will be generated from four different groups of respondents. These technocrats are involved in management of health finance at district council level, planners and implementers of MNCH programs at health facilities, community leaders at ward and village levels, and randomly beneficiary of MNCH care services from the selected regions and districts. Data for the technocrats and MNCH planners and implementers will be collected by using detailed unstructured interviews to get details of the policies and procedures available for communities’ participation in ensuring financial accountability. For the community members, data will be gathered through administering a one-to-one questionnaire with structured and semi-structured questions aimed at attracting their views, experience, and perceptions regarding the available financial accountability mechanisms (if there) and their capability to ensure financial accountability. The study will cover two regions, namely Kigoma and Rukwa, which have typical rural settings. In such regions, the need for the role of community in ensuring that there is financial accountability is very important since both of the two regions are among the few politically marginalized regions and thus the need for active personal initiatives by communities. Therefore, Kigoma and Rukwa will be selected as cases that may aid the researcher to generate answers that may be useful in explaining the same phenomena in regions with conditions similar to those of Kigoma and Rukwa. 6. Significance of the Study It is important to have an informed a study that seeks to explain why there is inadequate community quest for accountability in community based public health care programs, especially with a specific focus on financial accountability. This study is important since it starts where most of the studies that have been conducted regarding the factors that affect community based public health care initiatives have ended. Previous researches have uncovered the challenges and constraints that work against effective implementation of public health care programs, some have specifically looked at the need for accountability. This study goes further to fill the gap in literature by focusing on the mechanisms for ensuring financial accountability in community based health care programs and the capability (including knowledge and skills) of the users to hold accountable the service providers accountable in terms of cost and effectiveness of the services.

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