The desk review to explore the process and experience of Reforms in Public Sector in Tanzania while reflecting institutionalism approaches in public settings A Case Study of Health Sector Reform 1

The desk review to explore the process and experience of Reforms in Public Sector in Tanzania while reflecting institutionalism approaches in public settings A Case Study of Health Sector Reform 1.0 INTRODUCTION AND BACKGROUND INFORMATION Public service organization in many developed and developing countries have been reported to undertake changes after the Second World War. The changes were in order to implement public service management reform which was focused on various sectors such as defense, administrative, political, judiciary and economic. The reform facilitated changes in the government institutional for many countries in terms of the function to be performed by the organization, Structure to be followed, policies to be implemented, and accountability of the service rendered. (Pollitt et al, 20049-18) The introduction of Structural Adjustment Program (SAPs) in African countries by World Bank in the 1980s was the cornerstone for the changes in many African countries. The reform of the public sector in terms of procedures, regulations, laws, and structures took place in order to facilitate implementation of the program which was targeted to the entire population through donor assistance (WB, 2006). Tanzania in the last two decades experiences various reforms in a public sector which facilitated changes in the policy of country politically, economically and administratively. The restructuring of government institutions, Agency has been facilitated by the need of delivering quality service to the entire country by the public sector whereby the changes due to the anticipated changes the public institutions are accepted to increase performance in delivering of public goods (URT, 2005). The notable reform in Tanzania occurred immediately after independence was the adaptation of nationalistic approach whereby the country nationalized all major means of economy and the government becomes the major provider of all social services, decolonization of the administrative system, and declaration of one-party state under TANU in 1965.Implementation of the Arusha Declaration of 1967 up to the late 1980s which emphases on the socialism and self-reliance The government of Tanzania prioritized the reform of the Civil Service the program launched in 1991 with the focus of restructuring government organs in order to establish and control all system of delivery of the services and anticipate the size that needed to perform the function of the state. It has been reported by Mutahaba et al 2002 that the Civil Service Reform Program facilitated the government to undertake various actions toward managing the provision of service, introduces of Regulation and set of procedure to be followed by public institutions. The reforms were targeted to be implemented in three distinct phases. The first phase involves the installation of Performance Management Systems (PMS) in all Ministries, Departments, and Agencies Regions and Local Government Authorities. The objective of this phase was to improve accountability, transparency and resource management for efficient and effective delivery of quality services to the public (ibid). URT, (2005) explained that the aim of reform was to implement a shift from the state centred management approach to market economy and re-organize the government by changing its past practice of directly involving itself in the management of the economy to that of regulating the economy, supervising the market, managing the social affairs and providing efficient public services. The reforms targeted to make changes and formulate new institutions systems and structures featuring standard legalized behavior, coordinated operation, fairness, transparency, honesty and high efficiency for improved public social service delivery, management and hence promote sustainable economic growth. According to March and Olsen,(1989) revealed that the Rational Choice institutionalism emphases that the rules of the game are distinguished from the actual game within the institution this can be vividly observed in government operation due to the arranged and organized orders to ensure rules and incentives. Therefore the changes occurred in the institutions reforms included not limited to First a shift from discretionary administration to service-oriented administration by government improving legislation and push forward the effort to put the government work under the control of law and to establish improved social services Second a shift from administrative control system to law-ruling and regulatory administration system. Local Government Reform Programme in Tanzania was among the institutions changes occurred which aimed for quality services delivery in the local Authorities, Public Financial Management Reforms focused to ensure efficient use of resources in spite of resource constraints, Legal Sector Reform Programme in order to ensure rule of law and human rights are observed within public institutions and other Sectoral reform Programs such as Education, Agricultural, Health, security, economic etc were undertaken so that they can complement each other in service delivery to the public (URT,2004). 1.1 OBJECTIVE OF THE STUDY The main objective of desk review was to explore the process and experience of public sector reform, institutionalism approaches, factors influencing health institution reforms, Process of reforms and how the public and workers perceived the changes made after and before the reform. 1.2 METHODOLOGY The reviewer use desk review hence different books were consulted such as Institutional Theory in Political Science by B. Guy Peter (1998). Journals such as health politics and Law, International Journal of Social Science Tomorrow were explored. Review of Ministry of health strategic plans, Policy and guidelines was done in order to obtain the required information regarding health sector reform and reflection was made on the approaches of institutionalism 2.0 THEORETICAL REVIEW OF INSTITUTIONALISM APPROACH According to the Hall and Taylor (1996) explained that new institutionalism involves three school of thought which are historical institutionalism, rational choice institutionalism and social institutionalism, this approaches of institutionalism have been elaborated by Guy Peter (1998) when he argued on the development of historical institutionalism during the 1970s and the assumption of the interesting groups in managing scarce resource which facilitated the need to formulate and define clearly procedures, norms, regulation whether formal or not but the institutions/organization should be guided in order to produce the desired objectives. According to Oliver and Mossialos (2005) argued that the historical intuitionalist concentrate on how the power and authority of the institution are distributed differently in the group within the organization, the focus was why some individual within the institution is given the power to decide what will affect the whole institution. Hacker (2002) argues that historical institutionalism or path dependency is observed when the following are indicated (a) past policies have created large institutions with substantial set-up, (b) institutions benefit important organized interest groups whereby a large number of veto points are considered hence the changes of the policies may be occurring (Immergut 1992 Rittberger, 2003), (c) institution should represent long-term commitment (d) institutions replicate the broader cultural and economic values of the society (e)conditions put barriers in the path of change. Rothstein (1996) argued that historical institutionalists tend to believe that the development of the institutional mainly depends on the path which was the result of long-term policy plan within the institution. The institutions are guided by procedures, routines, norms, and convections within the structures event for its occurrences it has to take time to build it step by step in a proper way. According to Hall and Taylor (1996) explained that rational Choice is derived from the modern welfare economic this is the result of the understanding of the decision making and it is supported by the game theory. Furthermore, it was revealed that this approach was first observed during the study of American congressional behavior and views politics as a series of collective-action dilemmas. The rational institutionalist was revealed to apply a fixed and pre-defined set of preference which guides them to in attainment of the specified target of the institution. The achievement of the institutional objectives is characterized by different intervention within the organization. March and Olsen (1984) argued that rational approach has some features which distinguish it from other approaches the following are explanations for their opinions (a) Contextualism which emphases more on the society perspective where by the central role are shifted from the state to the society this is where the slogan of bringing the State Back in argued by various scholars (b) Reductionism the argument here is there must be a reduction of collective behaviour to individual once within the institution and this was emphasized on the approach of behaviour and rational choice where by individual within the institution are influenced by norms, values and rules of institutions (c) Utilitarianism explained that this is concerning the tendency whereby the decision made for individual on what they produce is valued compared to the inherent representation(d) Functionalism March and Olsen indicated how this features had come with the critics of the history aspect in institutionalisms where by the assumption was made that the society is moving from the lower to the higher forms thus structural functionalism must be observed(e) Instrumentalism this emphases on the domination of process, identity and socio-political values where by the action and process are conducted under the public sector umbrella rather than considering political process by itself . According Guy Peter (1999) explained five features of Traditional Institutional Approach which still exists in contemporary institutions as following (a) Legalism this assumption of traditional institutionalist whereby the central point of argument was concerns with law and the essential elements in governance of the any institution. Therefore, institution should have laws that will regulate behavior of the individual (b) Structuralism the importance of this assumption is that the behavior of the individual is determined by the structures of the organization. Therefore although structures of the organization help to attain its objective but also shape the employee within it. (c) Holism the argument was to obtain variation as more emphases was on formal legal (constitution) system analysis with formal structures in a whole system. Therefore the comparison aspect should be taken into consideration within the institution for the betterment to achieve the desired goals. (d) Normative argued that institution emerged from what is known as normative roots and the traditional institutionalists associated their critical analysis of the institution with the concern for good government that should be adhered. The normative characteristics of the institution basically described norms and values that persist in the institution. 3.1 THE REASONS FOR REFORMS IN THE HEALTH SECTOR URT,(2000) under POPSM elaborated that reform in public institution aimed to implement a transfer or shift of the state to centralize all management issues and give power and authority to the lower level to perform as per the directives whereby the essence of the market economy and efficiency can be realized. This also has been supported by the adoption of path dependency approach to the public institutions which argues on historical analysis of the institutions as they fail to produce what is the expectation of the community hence the changes were inevitable. The health institution underwent various changes after independence which facilitated the implementation of reform in 1994. Public sector reform in Tanzania was launched in 1991which targeted five key areas which are Micro-economic reforms, Public Finance Management reforms, Sectorial Reforms (health sector inclusive), Local Government reform and Public Service reform (URT, 1994). The reform mentioned above was carried out within government machinery and the emphases were to achieve Economic Growth and Quality public service to the citizen. 3.2 THE MAIN AREAS FOR THE HEALTH REFORMS PROCESS Institutions changes in health services delivery in Tanzania have long history thus why the concept of institutionalism of the reforms to the health sector machinery was easily practiced. The Ministry of Health prepared the proposal for the reform of the service delivery in the health sector which aimed to decentralise function of the central government to downward where the community lives, this intervention is supported also by the proponent of the institutionalism through argues from March and Olsen (1984) which said that bring back the state and community or individual whether within the institution or those who can be affected the institutions can observe rules and procedure from the government and also pose the feedback. Health sector organized changes which were based on situation analysis done by sectors, the analysis facilitated institutionalism within health sector which was grouped into the following Ideological reform, Organizational reform, Managerial reform, Financial reform, Public /Private Mix reform, Research reform, and Nutrition and Population reform. From these issues, the government proposed reforms that would seek to reinforce whatever strength existed in the health care system but also lead to improvement which will eliminate the weaknesses identified in the health sector. Although the above issues were identified in the 1990s its impact is observed also into the current regime whereby the President Dr. John Joseph Magufuli pronounced during the inauguration of Mloganzira Hospital that all Regional Referrals Hospital should be under the Ministry of Health by so doing the organization structure and institution are affected. Institutionalism in health sector occurred since independence and gained its momentum in the 1990s when different reform identified to take place and facilitate changes of policy, rules, and structures. The following are the key areas that were explored which facilitated health institution to changes as elaborated below The government implemented directives given by the ruling Party during the time of one party system where the party insisted on one ideological perspective. The party declared free service for all which facilitated people willingly to access service at any public facilities this was echoed from the Arusha Declaration 1967 which emphases on socialism and self-reliance and the government was declared responsible for delivering social service through Health sector policy (1991). The policy change for the free service facilitated the institution changes and hence more resources were needed in order for the wider spread of facilities (Dispensary and Health centers) through a contraction. This policy change did not mean that the government ignored its core responsibilities of providing free services (Kiondo, A., 1995). The argument for the existence of the sole provider came in to discussion hence resulted to occurrence of changes in health structures, the institutionalism of the conceptual that every Tanzanian should become responsible for his/her own health by taking active part in disease prevention and health promotion, and realises that health service provision is not free of charge was considered in the health sector. Finally, the government changes its policy from being the sole provider of services assume the role of a facilitator and advocate for solid partnership with the Private for-profit sector (Mgonja, 2014). The organizational reforms on health were basically on two main areas which are administrative and Managerial roles. Mponguliana, (2007) Indicated that the establishment of local government authority with the full responsibilities of administrative was facilitated through the structuring of the existed framework. The central government implemented the decentralization policy whereby each local authority (district/ council) was responsible for the running of health centers and dispensaries in its own district/council with financial support from the central government and their own sources. Regional and district hospitals were administered by the Ministry of Regional Administration and Local Government (MRALG) now PORALG. The process implementation of organizational reform did not occur rapidly in various stages went through such as critical discussion and argument on modalities and formulation of guiding principles. The MoHSW then was responsible for the national/referral/ specialized hospitals, health training schools, and national programmes. It was revealed by the Ministry of health that the approaches resulted in dual responsibilities at the district level, thus, an unclear line of authority and accountability and consequently, inappropriate utilization of manpower and improperly functioning referral system. These challenges facilitated the draft of reform proposal to suggest that there is a need to establish professional boards to resolve disputes concerned the health professional hence the government accepted and District Health Boards and Facility Committees be established, the overall task for managing quality and reporting mechanisms was need to be known by various actors. The Ministry of Health concentrate on its facilitation role of policy formulation, developing the guideline, legislation, regulations, standards, and control (URT, 1996) URT,(1990) explained that District Medical Officer was not the main responsible for health services delivery at District level this caused problems in terms of the managerial function of the health services. The issue of coordination of health services at a lower level which caused health intervention not done properly as directed by the Ministry of health. The concept of decentralization and primary health care was not well understood by both the policy maker and implementer and citizen at large. This triggered the establishment of guideline which will govern all planning activities at the District level, the guideline stipulated clearly the management procedure of all resource within the low level and how to coordinate donor fund. It is on to this aspect revealed that Health facilities are managed by the communities. Therefore, organizational reform in the health sector managed to bring changes in the structure within the health service delivery through implementation of Decentralisation policy. The financing of health interventions in developing countries Tanzania inclusive have been reported to be donor dependency since after the colonial regime (Gilson, 1997). In Tanzania context budgetary constraint has never been in favor of the government to sufficiently finance the extensive network of health facilities in the country. The underfunding was compounded by the fact that health expenditure was largely devoted to hospital care as a result of a combination of reasons institutional inertia, political influence, doctors professional lobbying etc. Until the mid 1990s, 57 of total Tanzanian health expenditure was spent on curative care, 11 devoted to community and 32 to preventive care (WB, 1997-a) Per capita expenditure on public health services by that time (1994- 96) was about the US 3.2 and for basic clinical services US 4.19 totalling 7.34 as compared to national target of US 12 . Within the health sector, it was found personal emoluments alone were taking almost 70 of the recurrent budget leaving only 30 of the recurrent for non-salary items As a result, most of the facilities suffered from a shortage of essential drugs and supplies as well as deteriorating infrastructure due to lack of adequate financing and weak management (URT-MOH, 1994). It is due to the budgetary constraint government took initiatives to overcome by introducing cost sharing through user fees in health services delivery early 1990s of which facilitated changes regulation and procedures to delivery service through introducing unit within the ministry and development of guideline to government the management of the intervention (Gilson, L., Russell, et al. 1995). The health sector in Tanzania developed and institutionalized different financing options including increased private financing- cost sharing, insurance, and private payments. The Ministry pretested community based pre-payment scheme (Community Health Fund-CHF ) in Igunga district and roll to other districts also the introduce National Health Insurance for civil servants and piloting of drug revolving funds at hospitals all these initiatives for overcoming underfunding of the sector facilitated structure changes in institution under health care (John M. et al, 2007). Institutionalism of Community Health Fund was as stipulate in the law that established it since 2001, the Act indicates that at the district level the management of Community Health Fund is under Council Health Service Board (CHSB) which has a composition of medical professionals and members who represent the community. The major roles of CHSB are to oversee the expenditure of all health funds collected within a district including cost sharing (URT, 2001). According the evaluation done by Chee et al (2002) indicated that Community Health Fund at the ward level is facing challenges in the management, collection, and enrolment because the facility in charge has multiple tasks to perform but also assigned the management role of the scheme as secretary of the board governing all health services at ward level. The government continues to improve this initiative through integrating it into the National Health Insurance (NHF) which also caused structure adjustment of the function under NHIF. The introduction of financing mechanism under Ministry of Health such as pay for performance, result based financing in recent years was due to the need of improving service delivery to the community. Institutionalism of this mechanism to the government existing machinery has affected sectors in terms of manpower and structures to ensure the proper delivery of the services (World Bank,2004) The collaboration of public and private sector in the delivery of health service has a long history since independence although after the Arusha declaration 1967 there had been no clear policy on the delivery of health services which favored the private sector participation in the delivery of health services in the country (COWI, 2007) However, with the amendment of the Private Hospitals (Regulation) Act of 1977 in 1991, it has been reported of rapidly increasing of Private health facilities specifically to the urban areas. The government allowed Private medical practice and adoption of the Trade liberalization policy which facilitated the incremental of private pharmaceutical stores and clinics in various areas. It relieved on the proposal for health sector reform in 1994 that during this period there were no reliable quality control mechanisms in place for private pharmacies/stores, nor regulation for traditional medical practice (Bennett, et al, 1994) The modalities of this partnership changes occurs time to time the study done by Bennett, S. et al (1994) on Public and Private Roles in Health in Sub-Saharan Africa revealed that Despite its importance, the private sector involvement in national health policy formulation has been hardly adequate, and there has been little cooperation and coordination of planning and delivery of health services among public, private, and voluntary agency providers. Due to the necessity of strengthening the partnership between public and private in the delivery of health services it was proposed that the government re-examine the relationship with the private sector, and create an environment that will promote the sound development of the private sector while of the adequate quality assurance and regulatory mechanisms are in place. The environment for partnership discussed were amendment of the existing Legislation on private practice to accommodate Clear definition of the facility being opened/registered Regular MoHSW supervision of the practice through an inspectorate unit at central level and the office of the RMO and DMO at their levels Different health cadres to operate private facilities offering services such as laboratory and maternity homes and Development of proper authority for checks and balances of the private sector. The government to ensure that more efforts are given on the rehabilitation and consolidation of existing health facilities and consider the construction of new primary health care facilities only when it is proved that the need of such facilities is great. Therefore, the proposed reform reflected what the proponent of the institutionalism approaches escalated on the assumption of new institutionalism that it is the duty institution to formulate order that will be followed by various actors, translation of structures so that every individual understand what to be done when changes occurred because reform is the process, institution are not static as before reform it was reported that no clear regulation thus the changes was necessary and inevitable process (Scott.W et al 2001). The institution responsible for health-related research has not existed before reform in Tanzania this made difficult to control and have are the credible source that the health sector may really on during medical and clinical interventions. The situational analysis conducted during the 1990s shows that research is initiated and conducted by academic institutions or outside the ministry for their own purpose. Furthermore, health intervention to overcome the problem of malnutrition in Tanzania was still far to be resolved compared to the world recommended standard. Reform initiatives, it was proposed to change and strengthening the existing health research units National Institute of Medical Research, Tanzania Food and Nutrition Centre, and the Health System Research unit at the Ministry of Health in order to bring positive feedback for the policy formulation and health service delivery to the entire community. The Tanzania Food and Nutrition Centre was charged to carry out programmes that would enable the country to achieve its National Nutrition goals which were set for the year 2000 and beyond as To reduce severe malnutrition from the 1990 rate of 6 to 2 or less and moderate Malnutrition from 46 22 by the year 2000. 3.3 Conclusion and Recommendations. The institutionalism approaches contributed to the active changes existed in healthcare systems for this review reflection was observed on health reforms and hence recognized that they are inevitable because every individual and organization experience changes occurred. It was identified that institutionalism approaches applied in health sector facilitated health institution structure, regulations, and guideline to change in order to incorporate needs identified and proposed during the reform. The Ministry should make the reform a continuity process due to the fact that during health sector reform a lot of changes happened but there is no clear roadmap for the sector to maintain good practices after the reform, the unit of research under Ministry of health should be given resource in order to have the capacity to conduct operation research. REFERENCE B. Guy Peter (1998). Institutional Theory in Political Science The New Institutionalism. Biddle Ltd, Continuum Great Britain. Bennett, S. and Ngalande-Banda, E. (1994) Public and Private Roles in Health A Review and Analysis of Experience in Sub-Saharan Africa, Current Concerns Series, SHS Paper No. 6. Geneva World Health Organization. Boniface E.S. Mgonja (2014) The New Institutional Approach to Understanding Good Governance in Tanzania, Vol. 2(11), International Journal of Political Science and Development. COWI, Gossy Gilroy INC. EPOS (2007) Joint External Evaluation of the Health Sector in Tanzania, 1999 2006. Gilson, L. 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