Key Findings from the Joint Field Trip

1. Key Findingsfrom theJoint Field Trip Conducted from 28th Sept-3rd Oct. 2015

2. Agenda • Short overview on teams and regions visited • Observed key issues and findings • Discussion

3. Overview • Main topic of the field trip: Human Resources for Health • Regions visited: Geita, Kigoma, Tabora • Visited places: District towns and remote villages in all regions • Visited Health Facilities: regional level, district level, and sub-district level facilities and training institutions and Zonal Resource centers • Type of HFs Visited: Both public and private facilities were visited in all regions • All teams had members from MoHSW, PMO-RALG, DPs, Civil Society Organizations

4. Key issue 1: shortage of available staff • Overall, postings by MoHSW are not matching the requests from the districts and regions What has been observed? • Positions remain unfilled, especially doctors, pharmaceutical and laboratory technologists and nurses • Training institutions are underfunded compared to their set objectives and targets, and they are therefore not operating at their fullest capacity • What is the recommendation? • Immediate Action: -Continue implementation and follow up on BRN initiatives of prioritized allocation of permits & redistribution of staff within regions - Districts to post pharmaceutical technologists and assistants at the health centers and dispensaries to manage medicines which is a critical challenge Policy Recommendation • Invest more in training of skilled staff, contract out/in and use private training institutions through a PPP arrangement, and • Break down the barriers and obstacles which hinder effective staff deployment as identified in BRN

5. Key issue 2: Attrition / low reporting rates • Allocated staff leave from postings or do not report to post What has been observed? • This issue depends on location and presence or absence of incentives/retention mechanisms • Some districts have mechanisms in place (housing, even basic furniture, school fees and also non-monetary incentives such as welcoming new staff by formal Region and District Leaders, recognition and appreciation of good work and support in times of need) • Statutory allowances are not paid on time What is the recommendation? • Immediate Action • MoHSW/POPSM to have and provide contact details of all posted staff available to RHMTs & CHMTs in advance of their arrival • RMOs to identify best practices within the regions on incentives/retention mechanisms and share these across the RMOs network, and support implementation within their own regions Policy Recommendation • Improve and roll out incentives/retention mechanisms including non monetary incentives • Improve flexibility of budget allocation to council levels for them to implement incentives/retention mechanisms • Allocate allowances timely as it is done for teachers • Introduce different salary levels according to remoteness (needs may be classification of areas) • Institute non monetary incentives as a routine! • Improve coordination between MoHSW, PMO-RALG and PO-PSM

6. Key issue 3: staff allocation • Staff allocation does not always correspond to workload, catchment areas What has been observed? • Facility classification does not always match with catchment area • Facilities on highways often overloaded • New facilities stand idle without service delivery due to late request for staff • Districts are prioritizing staff allocation • Gender and skill balance issues not adequately addressed What is the recommendation? • Immediate Action • MoHSW, POPSM, RHMTs & CHMTs to include consideration on gender &skill mix in implementation and follow up on BRN initiatives when prioritizing allocation of permits & redistribution of staff within regions • Policy recommendation • Plans to build new facilities go concurrently with HRH, funding and commodities planning • Synchronize implementation of the different existing strategies (MMAM, staffing guidelines, …) • Improve coordination between MoHSW, PMO-RALG and PO-PSM

7. Key issue 4: Leadership and Governance • Weak leadership and governance deteriorate health system performance What has been observed? • Differing levels of incentives and “care” for staff lead to differing retention rates, motivation and performance • Supportive supervision schedules are not done as planned due to unavailability of reliable transport and fuel. And when is done, it is in most cases conducted as policing and does not allow for dialogue on issues not mentioned in the checklist • Information sharing is incompletely executed • Lack of participatory planning at all levels • Lack of proper complaints handling mechanisms for most at most of H/Facilities • Accountability structures from community to District and Regional level are now operating effectively according to guidelines – understanding of roles, accountability etc. (HFGC, DHMB and CHMT etc) • HRHIS not updated regularly • Incomplete RHMT and CHMT teams • Essential guidelines are not available in most districts and HFs • Good cooperation between health sector leaders Private health Facilities in all LGAs visited

8. Key issue 4: Leadership and Governance (Ct) What is the recommendation? • Immediate Action • Install a proper complaints handling mechanisms in all Health Facilities • Post information, including composition, about HFGCs in all Health Facilities and provide guidelines to all committees from community, district and regional levels – especially after the new presidential decree of December 2014. • Implement systematic information flow processes between all levels of the system and between MoHSW and PMO-RALG (and PO-PSM) • Orient all health facilities with service agreements on the necessary guidelines/policies to facilitate proper HR management of government salaried and posted staff • Govt. (National and regional levels) to put more efforts on dissemination and distribution of guidelines to Regions, LGAs and HFs (the local and national media could be used for dissemination) • Change Supportive supervision guidelines to allow a more open dialogue • An independent review of the transport and fuel challenges and explore contracting out (possible assess what has been done and worked in other countries ) • Policy recommendation • Map accountability and ensure that it is present at all levels (Regions, RHMT, LGAs, CHMT and Health Facilities), and institute participatory planning and information sharing at all levels according to the new guidelines of PMO-RALG • Introduce regular benchmarking system on district management performance • Build capability including capacity of RHMTS, CHMTS, HFCGS and ensure core members available – again see the new guidelines, roles and functions of PMO-RALG. • Staff posted should fit the job and tasks that are required for the post, including leadership posts. • Ensure data quality audits and its management is done by all institutions

9. Key issue 5: Development of Human Resource for Health • Inadequate competence and quality of training for Nursing certificate course What has been Observed? • Tutors complained on the current duration (2yrs) that has led to omission of some topics or not to be taught in detail to cover the syllabus • Training Institutions are highly underfunded and without necessary working equipment(such as computers and transport) • Tutors not comfortable with competencies of their students at the end of their training • What is the recommendation? • Immediate action • The Government to reconsider its decision on training duration Policy recommendation • Review the annual budget ceilings for training Institutions, and • Consider PPP and involve private providers

10. Key issue 6: Functionality of Zonal Health Resource Centers • ZHRCs operates at its lowest potential What has been Observed? • ZHRCs have the task to build capacity of HRH and training institutions in their catchment areas but no clear budget allocated to them annually • No clearly defined working relationship between ZHRCs and RMO/RHMT What is the recommendation? • Policy recommendation • ZHRCs be allocated with budget to make them operate at its full potential • Clear working relationship between ZHRCs and RMO/RHMT be in place

11. Discussion Guiding questions • Are the recommendations given relevant to the observed issues? • What other recommendations could be added? • What issues are to be taken to the Policy meeting for higher level decision?