CHAs Partnering With CHAs Partnering With Governments through Governments through

MoUsMoUs

Euniace M.P. BandioEuniace M.P. Bandio

TCMA Assistant SecretaryTCMA Assistant Secretary

CSSC – TanzaniaCSSC – Tanzania

The DDH (CDH) Model of Partnership between Government and CSSC

Presentation OutlinePresentation Outline Brief about CSSC and how it functionsBrief about CSSC and how it functions Current partnership arrangements withCurrent partnership arrangements with

Government Government Church Health Institutions (CHIs) in Church Health Institutions (CHIs) in

TanzaniaTanzania The CDH/DDH ModelThe CDH/DDH Model

What is it and how does it functionWhat is it and how does it function What are the successesWhat are the successes ChallengesChallenges Lessons learnedLessons learned

The Christian Social Services The Christian Social Services Commission (CSSC)Commission (CSSC)

Ecumenical Organisation owned by two major Ecumenical Organisation owned by two major Church Authorities in Tanzania, TEC and CCTChurch Authorities in Tanzania, TEC and CCT

Responsible for supervising/coordinating Responsible for supervising/coordinating Church Health and Education ServicesChurch Health and Education Services

Coordinates approximately 40% and 24% of Coordinates approximately 40% and 24% of health and education services respectively in health and education services respectively in TanzaniaTanzania

Speaks for the churches to the Government Speaks for the churches to the Government on Health and Education Matters, while on Health and Education Matters, while Churches owns CHIs, CSSC oversees themChurches owns CHIs, CSSC oversees them

CSSC has decentralised into 5 Zones headed CSSC has decentralised into 5 Zones headed by Zonal Secretary of which a Zonal policy by Zonal Secretary of which a Zonal policy forum is the highest organ of the zoneforum is the highest organ of the zone

The Five CSSC Operational Zones

Current partnership Current partnership arrangements with arrangements with

GovernmentGovernment Currently there four kinds of Currently there four kinds of

agreements of which Church Health agreements of which Church Health Institutions are involved with the Institutions are involved with the Government namely:Government namely: MoU between Government and Churches MoU between Government and Churches

on on

CSSCCSSC Grant in Aid (GA)Grant in Aid (GA) Service Agreement Service Agreement DDH/CDH AgreementsDDH/CDH Agreements

Partnerships continues…Partnerships continues…

MoU between Government and MoU between Government and Churches on CSSC (1992)Churches on CSSC (1992) Signed by the Prime Ministers Office on Signed by the Prime Ministers Office on

behalf of the Government and Churches behalf of the Government and Churches (TEC/CCT)(TEC/CCT)

Recognising CSSC as a representative of Recognising CSSC as a representative of the Churches on Health and Education the Churches on Health and Education sector matterssector matters

Commitment to assist Churches and offer Commitment to assist Churches and offer training vacancies for Church Institutionstraining vacancies for Church Institutions

Grant in Aid arrangements RegulationsGrant in Aid arrangements Regulations The oldest of all available arrangement, The oldest of all available arrangement,

reviewed from time to time and the latest reviewed from time to time and the latest review is of 2002review is of 2002

Intended to assist Church hospitals (which Intended to assist Church hospitals (which are placed in rural areas) to offer services are placed in rural areas) to offer services to the community at affordable feeto the community at affordable fee

They include Bed, staff and training grantsThey include Bed, staff and training grants It is an official agreement and Government It is an official agreement and Government

commitment that its regulations are commitment that its regulations are functional after being published in the functional after being published in the Official GazetteOfficial Gazette

Partnerships continues…Partnerships continues…

Agreements continues…Agreements continues… The GA regulations has the The GA regulations has the

following objectives:following objectives: Government rationalising HS, by Government rationalising HS, by

making economical use of available making economical use of available resourcesresources

Attain equity of accessing HSAttain equity of accessing HS Provision of HS to the rural according Provision of HS to the rural according

to approved plans and strategies of to approved plans and strategies of the NHSthe NHS

Training of staff per available plansTraining of staff per available plans Minimise burden of paying fees for Minimise burden of paying fees for

clients utilising VAHclients utilising VAH

GA objectives continues …GA objectives continues … Ensuring that conditions of health Ensuring that conditions of health

care and health workers in VAHs care and health workers in VAHs are reflecting current economic are reflecting current economic situation, national norms and situation, national norms and standardsstandards

Assist Government in running Assist Government in running Preventive ServicesPreventive Services

Some of the Conditions for GA Some of the Conditions for GA arrangement include:arrangement include: Treating all persons without Treating all persons without

discrimination, denominational discrimination, denominational inclination, or obligation to religious inclination, or obligation to religious instructions or participating in instructions or participating in worshipworship

Establish and maintain infrastructure Establish and maintain infrastructure (building and equipment) and stock of (building and equipment) and stock of drugs to the standards satisfying the drugs to the standards satisfying the Director of Hospital Services (DHS) of Director of Hospital Services (DHS) of the Ministry responsible for Healththe Ministry responsible for Health

Employ and maintain sufficient staff to Employ and maintain sufficient staff to the set standardsthe set standards

Some GA Conditions continues…Some GA Conditions continues… In training centres, that all In training centres, that all

students are accepted without students are accepted without discriminationdiscrimination

Complying to the approved Complying to the approved syllabus by the MOHsyllabus by the MOH

Generally keeping satisfactory Generally keeping satisfactory books of accounts and permitting books of accounts and permitting representative of the Ministry to representative of the Ministry to visiting and inspect the grant visiting and inspect the grant earning Institution (transparency)earning Institution (transparency)

Service Agreement (SA)Service Agreement (SA) This is the latest PPP innovation in This is the latest PPP innovation in

TanzaniaTanzania It is not only for CHIs, but all Health It is not only for CHIs, but all Health

Service providers can go into Service providers can go into agreement including the pure private agreement including the pure private (PfP)(PfP)

It is between Councils and owners of It is between Councils and owners of health facilitieshealth facilities

Councils will purchase agreed Councils will purchase agreed services at agreed costs (though may services at agreed costs (though may be standardised)be standardised)

How does the SA function?How does the SA function? Objectives:Objectives:

To involve more the private sector in the To involve more the private sector in the delivery of health services thus strengthening delivery of health services thus strengthening the PPPthe PPP

To have a tool for measuring health services To have a tool for measuring health services and use of money provided by the Government and use of money provided by the Government to the private sector (value for money)to the private sector (value for money)

Intended useIntended use It is intended mainly for use when the It is intended mainly for use when the

Government and the private providers of health Government and the private providers of health services agree for the later to provide health services agree for the later to provide health services on behalf of the Government.services on behalf of the Government.

It does not in any way replace the Council It does not in any way replace the Council Designated Hospital Agreement currently in useDesignated Hospital Agreement currently in use

What are intended benefits What are intended benefits of the SA?of the SA?

Government to determine and monitor Government to determine and monitor (get value for money) the use of its (get value for money) the use of its funds disbursed to the private sectorfunds disbursed to the private sector

Allowing private providers of health Allowing private providers of health services receiving Government funds services receiving Government funds to justify their demandsto justify their demands

Provide the private providers of health Provide the private providers of health services reliable source of incomeservices reliable source of income

Availability of quality and affordable Availability of quality and affordable health services to the general health services to the general populationpopulation

Strengthen the partnership between Strengthen the partnership between Government and private sector as Government and private sector as required by the National Health Policy required by the National Health Policy

DDH/CDH – District Designated DDH/CDH – District Designated Hospital/ Council Designated Hospital/ Council Designated Hospital Hospital Contract between Church/other Contract between Church/other

organisation Hospitals and Government organisation Hospitals and Government Most of the DDHs are Church owned Most of the DDHs are Church owned

only one DDH and one proposed RDH only one DDH and one proposed RDH are owned by other Organisationare owned by other Organisation

They serve where there is no They serve where there is no Government owned Hospital in the area Government owned Hospital in the area to serve as the District or Council to serve as the District or Council hospitalhospital

Church Health Institutions in Church Health Institutions in TanzaniaTanzania

In Tanzania Our CHIs falls in In Tanzania Our CHIs falls in following categories:following categories: We have two Consultant Hospitals, We have two Consultant Hospitals,

KCMC and BMCKCMC and BMC GA, this is the biggest group among GA, this is the biggest group among

over 89 Church hospitals, they are over 89 Church hospitals, they are about 56about 56

DDH/CDH this group is growing faster, DDH/CDH this group is growing faster, though we have 24 Hospitals in this though we have 24 Hospitals in this arrangement, more are coming up and arrangement, more are coming up and about six are near to agreement.about six are near to agreement.

VAs which are neither GA nor DDH, VAs which are neither GA nor DDH, however these are few and mostly new however these are few and mostly new facilitiesfacilities

The DDH/CDH ModelThe DDH/CDH Model

What is the arrangement aboutWhat is the arrangement about How does it FunctionHow does it Function What are the successes of the What are the successes of the

arrangementarrangement ChallengesChallenges Lessons learnedLessons learned

The CDH ArrangementThe CDH Arrangement

It is between the Ministry of Health It is between the Ministry of Health and Social Welfare and the owner of and Social Welfare and the owner of the Hospital (i.e. the Church/Diocese)the Hospital (i.e. the Church/Diocese)

Now between the Council and Now between the Council and Diocese or Church or Organisation Diocese or Church or Organisation and the while the Ministry and the while the Ministry responsible for Health and CSSC are responsible for Health and CSSC are witnesseswitnesses

The agreement is composed of 29 articlesThe agreement is composed of 29 articles The DDH/CDH arrangement is intended The DDH/CDH arrangement is intended

to utilise a VA hospital as a District to utilise a VA hospital as a District Hospital where a Government facility is Hospital where a Government facility is not availablenot available

The Church shall retain ownership of the The Church shall retain ownership of the hospital and shall be responsible for hospital and shall be responsible for staffing, building, equipment and staffing, building, equipment and administrationadministration

The Centre must have all basic The Centre must have all basic infrastructure and staff needed according infrastructure and staff needed according to standard set by the Ministry to standard set by the Ministry responsible for healthresponsible for health

How does it worksHow does it works

Staff will be paid by Government, but Staff will be paid by Government, but employed by the Church, however the employed by the Church, however the Government may attach professionals who Government may attach professionals who are missing to meet staffing standards as are missing to meet staffing standards as per available guidelinesper available guidelines

The Government/Council will provide all The Government/Council will provide all recurrent expenditure while the recurrent expenditure while the Church/Diocese is responsible for capital Church/Diocese is responsible for capital expenditureexpenditure

The Hospital shall be required to prepare The Hospital shall be required to prepare and submit quarterly financial and and submit quarterly financial and Technical reports as per Government Technical reports as per Government regulationsregulations

Both the Council and Church Both the Council and Church participates in the Governing boardparticipates in the Governing board

Governing Board recommended to Governing Board recommended to have 10 members of which 6 have 10 members of which 6 appointed by the Church and 4 by the appointed by the Church and 4 by the Government, Chair appointed by the Government, Chair appointed by the ChurchChurch

The Church shall nominate the MO i/c The Church shall nominate the MO i/c or Director of the Hospital and be or Director of the Hospital and be appointed by Governing boardappointed by Governing board

The running funds for the hospital will be The running funds for the hospital will be provided by the Government as for other provided by the Government as for other Government hospitalGovernment hospital

Equipment and supplies for the hospital Equipment and supplies for the hospital are exempted as for other Government are exempted as for other Government hospitalshospitals

Patients will receive services free or at a Patients will receive services free or at a fee as it is in public institutionsfee as it is in public institutions

There is room for review, where a There is room for review, where a necessity risesnecessity rises

Though ownership remains to the Though ownership remains to the Church, any expansion must be Church, any expansion must be approved by the Governmentapproved by the Government

The Hospital maintains discipline of The Hospital maintains discipline of all staff including those attached by all staff including those attached by the Governmentthe Government

Running costs should be 100% from Running costs should be 100% from Government, but in case of under Government, but in case of under funding of the sector PE (salary) is funding of the sector PE (salary) is assuredassured

SuccessesSuccesses Quality services near to the people Quality services near to the people

(especially the rural community)(especially the rural community) Most reliable source of income and Most reliable source of income and

stable running of Hospitalstable running of Hospital Making PPP a realty and very well Making PPP a realty and very well

understood at high levels (Central understood at high levels (Central level)level)

There is recognition on the There is recognition on the Government side on the contribution Government side on the contribution of such Hospitals to the health care of such Hospitals to the health care systemsystem

The Health Policy recognises the The Health Policy recognises the presence of a DDH/CDH, thus even if presence of a DDH/CDH, thus even if the Council constructs another facility the Council constructs another facility the DDH will continue receiving the DDH will continue receiving Government disbursementsGovernment disbursements

Staff availability guaranteedStaff availability guaranteed Growing fast, as in very near future we Growing fast, as in very near future we

will be having 30 Church Hospitals are will be having 30 Church Hospitals are working as DDH/CDH (they were 24 in working as DDH/CDH (they were 24 in Sept. 2008) fast growingSept. 2008) fast growing

Every owner of Church Hospital Every owner of Church Hospital seeks opportune time to make the seeks opportune time to make the facility a DDHfacility a DDH

ChallengesChallenges LGA does not see the facility as theirs, LGA does not see the facility as theirs,

they long for ownership, while facilities they long for ownership, while facilities sees it as they have direct access to the sees it as they have direct access to the MOHSWMOHSW

Cooperation with DMOs is limited at Cooperation with DMOs is limited at times there are conflicts of interest – times there are conflicts of interest – DMO has no power to the HospitalDMO has no power to the Hospital

DDH/CDH gets funds directly from DDH/CDH gets funds directly from Central Government, Councils have no Central Government, Councils have no hand on themhand on them

Under-funding of the health Under-funding of the health sectorsector

Exemptions are losses no Exemptions are losses no Authority responsible for Authority responsible for reimbursementreimbursement

Transparency and trust on both Transparency and trust on both sides is limitedsides is limited

Lessons LearnedLessons Learned It is possible to realise partnership It is possible to realise partnership

even at the Local Government (LA) even at the Local Government (LA) levellevel

Effective utilisation of available Effective utilisation of available resourcesresources

We need to build trust and We need to build trust and transparency to have successful transparency to have successful partnershipspartnerships

Churches can use finances for other Churches can use finances for other development programmesdevelopment programmes

Lobbying and advocacy are key to Lobbying and advocacy are key to successful partnership need to be successful partnership need to be intensifiedintensified

DDH/CDH is a great success DDH/CDH is a great success partnership model and seem to be partnership model and seem to be attracting Churches, in the attracting Churches, in the beginning it was not very much likedbeginning it was not very much liked

DDH/CDH Model can stand as an DDH/CDH Model can stand as an example of partnership in lobbying example of partnership in lobbying for the Service Agreementsfor the Service Agreements

Not every Hospital can be a Not every Hospital can be a DDH/CDH but every Dispensary, DDH/CDH but every Dispensary, Health Centre, Hospital and any Health Centre, Hospital and any other facility can enter Service other facility can enter Service Agreement with CouncilAgreement with Council

Lastly but not least would like to Lastly but not least would like to thank all those who made it possible thank all those who made it possible for me to attend this Conference for me to attend this Conference including:including: CSSC DirectorCSSC Director CHAs SecretariatCHAs Secretariat Colleagues in Uganda (UCMB and UPMB) Colleagues in Uganda (UCMB and UPMB)

for hosting usfor hosting us Donors and friends from AbroadDonors and friends from Abroad Colleagues from CHAs in AfricaColleagues from CHAs in Africa The AudienceThe Audience Etc. etcEtc. etc

Thank you very much for your Thank you very much for your kind attentionkind attention

Mwebale kumpulilizaMwebale kumpuliliza

Ahsanteni kunisikilizaAhsanteni kunisikiliza

Merci de Votre Attention Merci de Votre Attention aimableaimable