Effects of Direct Health Facility Financing on Health System Performance and How It Is Implemented in the Public Primary Health Facilities in Tanzania: A non-controlled before and after mixed method study.

Abstract

Background: In Tanzania, the introduction of Direct Health Facility Financing (DHFF) is viewed as one of the innovative health sector reform initiatives, with the main focus of improving quality of health services provision. DHFF empowers primary health care actors’ autonomy in decision making to improve health system performance in the stride forward to reach Universal Health Coverage (UHC). The purpose of this study was to assess the effect of DHFF on health system performance and how it is implemented in the Public Primary Health Facilities (PPHFs) in Tanzania. Methods: This study used a non-controlled before- after convergent mixed-method study design, with a process evaluation embedded at midline, in data collection and analysis. The study was conducted between January 2018 and September 2019. Quantitative data collection was done through administration of questionnaire to 844 existing patients and 238 Health care workers in 42 Public Primary Health Facilities of seven regions whereas qualitative data was collected using semi-structured individual interview guide for 14-indepth interviews with health facility in-charges, members of health facility governance committee, district medical officers and district DHFF coordinators and 7 Focus Group Discussions with service providers and users representatives. We used descriptive and inferential statistics to analyse quantitative data whereas a thematic analytical approach was used for qualitative data. Results: A total of 844 patients were studied on seven domains of Health System Responsiveness (HSR) both in the before and after studies. All domains of HSR were found to have positive significant difference between baseline and end-line except for two domains i.e., confidentiality and communication. Also, of all 42 investigated public primary health facilities. Majority (88.9%) of Dispensaries and 60% of Health Centres were below the required staffing level. There were significant differences on structural quality of maternal health services before-and-after studies with scoring 2.38% and 30.9% respectively. Moreover, there were significant differences in all indicators after DHFF introduction except those for IPT2, use of modern family planning methods and Mebendazole consumption. Furthermore, about 238 health care providers were studied on the Fidelity of Implementation (FoI), of whom about 76% had knowledge on DHFF initiative implementation issues. However, only 28% had high FoI. Conclusion: In general, it is clear that, DHFF have had an effect on the health system performance. FoI was low despite training been offered to HCPs (Health Care Providers), this calls for more investment on this aspect so that to have a resilient health system.