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Circumventing ‘ free care ’ and ‘ shouting louder ’ : using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania

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ABSTRACT

Background: Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable.

Methods: In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there.

Results: Practitioners in this region felt eye care was systemically neglected by government and therefore was ‘all under the NGOs’, but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain ‘sustainability funds’ to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for ‘free care’. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system.

Conclusions: Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs’ investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation.

Electronic supplementary material: The online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.

No MeSH data available.


Schematic of revenue streams available to eye departments in case study hospitals in 2012
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Fig1: Schematic of revenue streams available to eye departments in case study hospitals in 2012

Mentions: In 2012, three out of the four eye departments we studied had ‘sustainability funds’. Government Hospital A did not, and relied entirely on the hospital to provide income for consumables and any other purchases they needed (Fig. 1). As all other teams received donor funding, it is possible that the verticality of donor accounting processes helped initiation of separately-controlled eye accounts in these hospitals. In both Government Hospital B and Mission Hospital A, a portion of patient fees revenue was given to the hospital to enable central purchases, but the eye department eventually received the value back in-kind through some consumables and access to hospital infrastructure. In the mission sector, teams had more financial independence; Mission Hospital A staff, for example, rarely had to negotiate permission to use funds for outreach activities or professional development expenses such as attendance at zonal or international meetings.Fig. 1


Circumventing ‘ free care ’ and ‘ shouting louder ’ : using a health systems approach to study eye health system sustainability in government and mission facilities of north-west Tanzania
Schematic of revenue streams available to eye departments in case study hospitals in 2012
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5017067&req=5

Fig1: Schematic of revenue streams available to eye departments in case study hospitals in 2012
Mentions: In 2012, three out of the four eye departments we studied had ‘sustainability funds’. Government Hospital A did not, and relied entirely on the hospital to provide income for consumables and any other purchases they needed (Fig. 1). As all other teams received donor funding, it is possible that the verticality of donor accounting processes helped initiation of separately-controlled eye accounts in these hospitals. In both Government Hospital B and Mission Hospital A, a portion of patient fees revenue was given to the hospital to enable central purchases, but the eye department eventually received the value back in-kind through some consumables and access to hospital infrastructure. In the mission sector, teams had more financial independence; Mission Hospital A staff, for example, rarely had to negotiate permission to use funds for outreach activities or professional development expenses such as attendance at zonal or international meetings.Fig. 1

View Article: PubMed Central - PubMed

ABSTRACT

Background: Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. In the specialist area of eye health, international and domestic Christian FBOs have been important contributors as service providers and donors, but they are also commonly critiqued as having developed eye health systems parallel to government structures which are unsustainable.

Methods: In this study, we use a health systems approach (quarterly interviews, a participatory sustainability analysis exercise and a social network analysis) to describe the strategies used by eye care practitioners in four hospitals of north-west Tanzania to navigate the government, church mission and donor rules that govern eye services delivery there.

Results: Practitioners in this region felt eye care was systemically neglected by government and therefore was ‘all under the NGOs’, but support from international donors was also precarious. Practitioners therefore adopted four main strategies to improve the sustainability of their services: (1) maintain ‘sustainability funds’ to retain financial autonomy over income; (2) avoid granting government user fee exemptions to elderly patients who are the majority of service users; (3) expand or contract outreach services as financial circumstances change; and (4) access peer support for problem-solving and advocacy. Mission-based eye teams had greater freedom to increase their income from user fees by not implementing government policies for ‘free care’. Teams in all hospitals, however, found similar strategies to manage their programmes even when their management structures were unique, suggesting the importance of informal rules shared through a peer network in governing eye care in this pluralistic health system.

Conclusions: Health systems research can generate new evidence on the social dynamics that cross public and private sectors within a local health system. In this area of Tanzania, Christian FBOs’ investments are important, not only in terms of the population health outcomes achieved by teams they support, but also in the diversity of organisational models they contribute to in the wider eye health system, which facilitates innovation.

Electronic supplementary material: The online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.

No MeSH data available.