Enabling community participation and oversight in the planning and budgeting of Tanzania’s health services
As part of the country’s decentralisation process, Tanzania’s health facilities take on the tasks of planning and budgeting of health services. In the Mbeya and Tanga regions, a Tanzanian-German project has set up structures and systems for effective community participation.
An interesting scene is playing out in Lupa Tingatinga village in Tanzania’s Mbeya region in the far west of the country. White sheets of paper are taped to the side of a van in the middle of a dusty street, and two elderly men are standing in a group discussing waiting times at their local health facility. One complains he has to wait for hours, while the other explains the different stages that make up a routine visit to the health centre – registration, consultation, tests, medicines from the pharmacy, and so on through the pathway of care. Every now and then, someone from the group interjects, and there is nodding and shaking of heads as the discussion advances. Off to the right, women sit in the shade having their own animated discussion while in the other direction, a group of young people are talking about why they sometimes visit the drug store rather than going to their local health facility.
Aligning stakeholders behind efforts to improve service quality
This is day two of the Community Scorecard exercise, designed to bring the diverse voices of community members into efforts to improve the quality of services. Timed to coincide with the budget cycle so that planned activities have a greater chance of being funded, the Scorecard is a bottom-up planning process which takes place in October or November, prior to the new financial year in July. Over two days, health centre staff first review their own performance and quality of services against the national standards of care. They then present their findings to community members in their catchment area, who have an opportunity to discuss and present their views in an open and safe environment.
The President’s Office, Regional Administration and Local Government (PO-RALG) is responsible for implementing health policies at regional and local levels. Facilitators from PO-RALG’s regional offices support the exercise, which culminates in an agreed costed action plan for the health facilities. In theory, the costed plan is then incorporated into district plans and on up through the system where it becomes part of the central level budget preparations. Of course, as in most resource-constrained countries, the funds flowing in the other direction almost never reflect the entirety of the original budgets and difficult decisions have to be taken.
But the exercise has many benefits. As Dr Manyatta, Regional Medical Officer for Mbeya, says, ‘it’s about closing the gap between the facility and the community. We are aligning stakeholders – community members, health facility staff, local managers and even local politicians – behind the objective to improve the quality of care.’
In Tanzania, the Community Scorecard is being supported by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ) in eight health centres in Tanga and Mbeya as part of the Improving Health Care Provision project.
It’s not only about quality but about governance and accountability
The community scorecard is one of a number of social accountability mechanisms that aim to enhance citizens’ ability to participate in decision making about their health services and to hold health service providers and managers to account. Enhancing citizen participation and accountability are key objectives of Tanzania’s decentralisation process that began in the 1990s, and which, in 2018, began to devolve responsibility for planning and budgeting to the health facilities through the Direct Health Facility Financing reform. The Tanzanian-German Health Programme is working to improve the functioning of Health Facility Governance Committees and Council Health Service Boards, which are the principal accountability structures with oversight for these functions.
Bringing the best of social audit from Nepal
Tanzania’s community scorecard methodology is similar to what is often called ‘social audit’ in other countries, which is an approach that has been practiced widely in low- and middle-income countries since the 1990s. When former Project Team Leader Susanne Grimm arrived in Tanzania in 2014, she brought in-depth experience of supporting social audits with her from Nepal (see this GHPC case study for more details about the German-supported social audits in Nepal). As the community scorecard was already being used in Tanzania as a tool for civil society to monitor the implementation and financing of public health services, the project team set out to integrate the most successful aspects of the social audit process into the existing scheme.
They started by inviting a Nepalese expert to talk to the Ministry of Health about the potential benefits of widening participation to bring communities together with those engaged in the delivery and management of the services. The aim was to build trust between the parties and provide a real opportunity for communities to participate in a bottom-up planning process. While the ministry liked the broader approach, the proof of concept lay in trialling this adapted methodology. Tanzania has a very different culture to that of Nepal and it wasn’t clear whether people would speak up and, if they did, whether the government would perceive this to be criticism.
So does it work?
In the event, the new scorecard methodology was a success. As Ms Grimm said, ‘this triggered a huge engagement of the users of health services. Within one year, there was real change – health facilities that had not had a water supply for decades got water, and our initial concerns that citizens would not speak up and that government officials would take comments in the wrong way did not happen.’ Other simple but important changes at participating facilities include improved organisation of health staff to cope with busy morning clinics, changes in opening hours and improvements in staff attitudes to patients. Complaints processes have started to function.
However, it has not all been plain sailing. Political challenges and the advent of Covid-19 served to delay the roll-out of the approach. And while activities resumed in 2021, challenges remain, including how to ensure continual monitoring of health facility action plans, the need to find funds for facilitation and coordination from already inadequate district budgets, and how to motivate communities at a time when many people face considerable difficulties. As Dr Manyatta said, ‘we are struggling to sensitise the facilities. The process needs continual engagement by us, and you need good quality facilitators, which is not a simple thing. Councils have to budget – and sometimes due to financial scarcity you find that some activities are not financed or prioritised.’
Some important lessons have been identified that could prove useful to other organisations supporting these efforts.
Community ownership and action are as important as participation
For years, the status quo in Tanzania has reflected the idea that the state will provide and citizens are passive recipients of health services. The Community Scorecard aims to show communities that they can make a real difference. To paraphrase a Swahili proverb, a few pennies here and there will eventually fill the piggy bank. Dr Sijaona, national Community Scorecard Facilitator said, ‘we wanted the communities around the health centres to be responsible for supporting the quality of the services. This is the core of the scorecard work – they must do something to help’. Community members have readily donated land and even income from their harvests, and some also give their time by working as community health volunteers.
Expert facilitation enables a diversity of voices
The importance of expert facilitation is another key lesson. All discussions, whether at the facility or in the community, are expertly moderated so as not to end up in a blame game, and to ensure that those with the loudest voices do not dominate the conversation. Discussions in the community take place in separate groups of women, young people, elders and men, to encourage more open debate. As Dr Manyatta explained ‘the facilitator is tasked with helping the silent people to speak up and to reach a consensus’.
Preparing for the future by institutionalising the approach
Building on Germany’s expertise in health systems strengthening, the project has helped to institutionalise the community scorecard approach in several important ways: by training a national group of expert facilitators who are mentoring facilitators in the districts; by supporting the development and dissemination of national guidelines and tools in Swahili; and by designing a process that is low-cost and can more easily be assimilated into local budgets; and by linking the scorecard to Tanzania’s budget cycle. As Governance Adviser Erick Msoffe states, ‘we quantified the additional resources, generated by the communities themselves, that resulted from the scorecard exercise – both financial and in-kind – over one year. The resources which went to the health facilities (for example, buying solar panels, building fences, improving the water supply and so on) were huge compared to the annual budget provided by the government. It makes a really big difference.’
Corinne Grainger, February 2022