A Case of Maternal Health in two Districts of North-West Tanzania

PhD Thesis Proposal Presentation

Respicius Shumbusho Damian Department of Political Science & Public Administration College of Social Sciences

Community Role in Promoting Financial Accountability in Rural Healthcare:

University of Dar es Salaam, Tanzania

Supervisor: Prof. Benson Bana & Bernadeta Killian
Presented at Safari Park Hotel, Nairobi-Keya, April 1, 2014

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Outline
oBackground and Context oResearch Problem /Question oResearch Objectives oProposed Conceptual Framework

oProposed Design and Methods

oReference

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Background and Context

Tanzania has been 1 of the leading countries in prioritizing and addressing critical health problems in Africa.(1) Financing (government and DPs) to reduce preventable deaths of women has been a critical concern since 1989. (1, 2) Government spending on health increased from Tshs 143.6 million to 1,288.7 million between 1999 and 2013. In 2013, 31% was devoted to maternal healthcare. Reliance on donors and DPs decrease from 56.1% to 40% between 2000 and 2010. (3)

GBS declined from 77% to 26% between 2006 and 2013, but Domestic Health Expenditure Share increased from 43.9% to 56.9% in 2005.(3)
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Background and Context

2001-2013, average financial commitment was sustained above 10%.The highest was 13.8, in 2012 (close to 15%, Abuja Declaration). (3, 4). 2012/13 (13.4%), 2013/14 (10.8%)**. PARADOXY: Insignificant Returns; MMR is still unnecessarily and unpredictably high standing at 460/100,000 live births. (4) (compared with Kenya and Uganda).

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Research Problem/Question
Significant increase in financing, but preventable health problems persist (average maternal mortality rate around 460) (5, 6,7) Existing research and Literature attribute this to mismanagement of finance (only 39.2% justifiable, 61.2% =seminars and workshops (8,9) Consensus: Communities role is critical in managing healthcare financing for the best returns (effectiveness)(10,11,12), but little consensus whether communities in the Tanzanian context are capable-also, what makes up the so called community (13) Efforts: to empower community actors increasingly supported, but impact on financial accountability promotion remains questionable.(14,15) ???What practically is the role of communities in promoting financial accountability in rural healthcare. How and in what capacity are community actors able to play such a role? [Given the Context]

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Research Objectives (to)

Objective 1: Identify actors and their specific roles in ensuring financial accountability practices Objective 2: Review accountability mechanisms in place for community actors to play their role in promoting financial accountability.

Objective 3: Review how the mechanisms in place hinder/facilitate community actors role in promoting financial accountability.
Objective 4: Examine capability of community actors to influence financial accountability in rural maternal healthcare Objective 5: Propose a framework for enhancing communitybased financial accountability promotion in the context of rural maternal health care.
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Proposed Conceptual Framework

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Proposed Design and Methods

Design: Case Study-maternal health care a typical health challenge in Tanzania and other developing countries Typical case concern of global health, yet challenging in developing countries rural communities' context) Why?: Not generalizing, but gaining deeper insights based on peoples experiences, beliefs, meanings in particular context. (2 rural districts used for that purpose)

Focus: systems (actors, structures, process, structures, institutional (soft) procedures ) that shape interactions
Participants (150): Bureaucrats, technocrats, facilities (14), community leaders, governing structures, Organized Community groups representatives (36) Direct beneficiaries of MHC (100 respondents in the two districts-selected randomly (only) to control bias
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Two first categories selected purposively, possibility of snowball, the third category located through multistage random sampling, selected using simple random sampling. Data Collection and Analysis: the two to overlap, focus on objectives [mainly focused ethnography methods]. Obj 1: (Actors and their specific roles) Co: Key informant interview, Observer as participant; An: Interpretive Content Analysis, Doc Rev Obj2: (Mechanisms Available): Co: Documentary Review, Key Informant Interviews, Observer As Participant. An: Interpretive Content Analysis Obj3: (Facilitating/hindering): Co: Ethnographic FGD, Semi-structured Interview questionnaire (one-to-one, self-administered-3rd Category ). An: Thematic Content Analysis, Qualitative Analysis of Descriptive Statistics (processed by SPSS) Obj4: (Actors Capability): Co: SSIQ and OAP. An: thematic/interpretive Content Analysis, QADS. Obj 5: Propose a framework (descriptive induction from findings 1-4)
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Proposed Design & Methods...

Ethical Standards and Mechanisms

Methods, tools, and questions discussed with supervisor and senior department researchers, and presented to for approval Proposed methods and tools submitted to the college postgraduate committee (ethical review and approval) Community entry procedure: Seek approval and permits, build positive working relationship with administrative and community authorities.

Informed Consent for all Participants: Clarity of purpose, use of data, benefits, risk, confidentiality, voluntary participation, open contact to institution).
Post Research Engagement: Strategy for sharing findings, and empowerment for CSOs engaged in policy analysis and advocacy in the 2 districts. Linking key CSOs with other national and international partners supporting community accountability empowerment. Support CSOs in testing the designed framework.
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Key References
1. Kiria, I. B. (2009). Downward Accountability in Public Health Care Systems: The Case of Temeke Municipal Council, . Muhimbili University of Health and Allied Sciences. Dar es Salaam.
Mswia, R., Lewanga, M., Moshiro, C., Whiting, D., Wolfson, L., Hemed, Y. P, S. (2003). Community-based monitoring of safe motherhood in the United Republic of Tanzania. Bulletin of the World Health Organization, 81(1), 87-94. Swiss Development Cooperation. (2010). Swiss Cooperation Strategy for Tanzania 2007-2010: Swiss Development Cooperation WHO, UNICEF,UNFPA, and World Bank (2012), Trends in Maternal Mortality: 1990 to 2010, WHO, UNICEF,UNFPA, and World Bank, https://www.unfpa.org/webdav/site/global/shared/documents/publications/2012/Trends_in_maternal_mortality_A4-1.pdf Kanungo, P. (2005). Public Expenditure Tracking Surveys Application In Uganda, Tanzania, Ghana And Honduras, Washington: World Bank. Strengthening Health Outcomes through Pivate Sector Project. (2013). Tanzania Private Health Sector Assessment Brief MD. Bethesda: Strengthening Health Outcomes through the Private Sector Project, Abt Associates. Lawson, A & Rakner, L (2005), Understanding Patterns of Accountability in Tanzania: Synthesis Report, Dar es salaam: Oxford Policy Management and Report on Poverty Alleviation Mushi, R., Melyoki, L., & Sundet, G. (2005). Improving Transparency of Financial Affairs at Local Government Level in Tanzania. Brief No. 2. Dar es Salaam: Research on Poverty Alleviation (REPOA). Mwaikambo, E. (2010). Improving Maternal, Newborn and Child Health in Tanzania: From Science to Action, . Paper presented at the Third Professor Hubert Kairuki Memorial Lecture, , Dar es salaam. 2.

3. 4.

5. 6.

7.

8.

9.

10. Brinkerhoff, D. (2003). Accountability and Health Systems: Overview, Framework, and Strategies: Abt Associates Inc. 11. Cooksey, B & Kikula, I, (2005).When Bottom-up meets Top-down: The Limits of Local Participation in Local Government Planning in Tanzania. DSM: M. N. Publishers. 12. World Health Organization. (2012). Addressing the challenge of women's health in Africa. A Summary of the 13. Checkland, K., Allen, P., Coleman, A., Segar, J., McDermott, I., Harrison, S., . . . Peckham, S. (2013). Accountable to whom, for what? An exploration of the early development of Clinical Commissioning Groups in the English NHS. BMJ Open, 3(12). doi: 10.1136/bmjopen-2013-003769 14. United Republic of Tanzania. (2013). Public Expenditure Review 2013. Dar es salaam: Retrieved from http://mof.go.tz/mofdocs/news/PER NEWSLETTER Final.PDF. 15. Muhondwa, E. P. Y., Nyamhanga, T., & Frugence, G. (2008). Petty Corruption in Health Services in Dar es Salaam and Coast Regions. Dar es Salaam Youth Action Volunteers.

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-ENDHappy and Safe & Motherhood: Is it Possible?

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