Acceptability of the Direct Health Facility Financing (DHFF) initiative in Tanzania: A mixed methods process evaluation of the moderating factors

Do community health committees participate in governing health workers in primary healthcare facilities under fiscal decentralization?-An explanatory qualitative study from Tanzania

Background

Decentralization is implemented at the local level to increase community participation in improving service delivery. Majority of developing countries are implementing Fiscal decentralization in primary healthcare through various approaches such as Direct Health Facility Financing, among other things, to empower Community governance structures to govern Primary Health Facility operations to improve the responsiveness of health service delivery and achieve Universal Health Coverage. One of the primary functions of these governance committees is to oversee health workers in their health facilities.

Aims

This aimed at assessing how empowered governance committees govern health workers in their facilities under fiscal decentralization.

Methods

To collect data for this study, an explanatory qualitative design with phenomenology traditions was used. To select the area of study, health facilities, and participants, a purposeful sampling procedure was used. Data were gathered through interviews and Focus Group Discussions to explore committee participation in governing health workers in primary care. Thematic analysis was used to analyze the collected data.

Result

The findings of the study suggest that community governance committees' participation in governing health workers under fiscal decentralization remains limited. Majority of the committees have found to have low limited participation in governing different aspects of health workers. The majority of the committees have discovered that hiring casual workers such as security guards and cleaners is more important than other functions.

Conclusion

The study implies that lower and middle-income countries' willingness to implement fiscal reforms at the local level and empower communities to take the lead in governing health workers still there are very limited specific powers granted to them to govern health workers. Therefore, capacity building to the governance actors is critical if we are to achieve the benefit of fiscal decentralization.

Who makes health governance decisions at the local level? A cross sectional study from primary health facilities in Tanzania

Background and Aims

Lower- and middle-income countries have decentralized decision-making at the community level, as well as community governance structures, to encourage community participation in governance processes, particularly in primary healthcare (PHC). In Tanzania, decentralization resulted in the establishment of Health Facility Governing Committees (HFGCs) to encourage community participation in the governance of primary health facilities to improve the quality and responsiveness of health service delivery. Nonetheless, despite the presence of HFGCs, PHC delivery remains ineffective and of poor quality. It is unclear who makes governance decisions at PHC facilities to ensure that services delivered are of expected quality and respond the community's needs, tastes, and preferences. This paper aims to assess the perspectives of members of the HFGC on who make governance decision in the context of fiscal decentralization.

Design and Methods

A cross-section design was used to collect both quantitative and qualitative data. A four-multistage sampling technique was adopted to selects regions, council, health facilities, and HFGC members. Respondents who participated in structured questionnaire responses were chosen using proportional sampling, whereas those who participated in in-depth interviews and Focus Group Discussions were chosen using purposive selection. The data was analyzed descriptively and thematically.

Results

The study revealed that HFGCs members perceive that governance decisions in primary health facilities are primarily made by the health facility management, and later are presented in HFGCs. As such, HFGCs are used a passively used to justify participation in decision that was already made by the management, which contradict with the principal of decentralization that emphasizes community participation on fiscal decisions.

Conclusion

Decentralization of PHC facilities does not guarantee the participation of community members in fiscal decision of their respective primary health facilities through HFGCs. HFGC is passively used governance structure to substitute community participation in primary health facilities' fiscal decisions. Enforcement mechanisms are required to facilitate effective community participation.