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Background: Infrastructure development and upgrading to support safe surgical services in primary health care facilities is an important step in the journey towards achieving Universal Health Coverage (UHC). Quality health service provision together with equitable geographic access and service delivery are important components that constitute UHC. Tanzania has been investing in infrastructure development to offer essential safe surgery close to communities at affordable costs while ensuring better outcomes. This study aimed to understand the public sector’s efforts to improve the infrastructure of primary health facilities between 2005 and 2019. We assessed the construction rates, geographic coverage, and physical status of each facility, surgical safety and services rendered in public primary health facilities. Methods: Data was collected from existing policy reports, the Services Availability and Readiness Assessment (SARA) tool (physical status), the Health Facility Registry (HFR), implementation reports on infrastructure development from the 26 regions and 185 district councils across the country (covering assessment of physical infrastructure, waste management systems and inventories for ambulances) and Comprehensive Emergence Obstetric Care (CEMONC) signal functions assessment tool. Data was descriptively analyzed so as to understand the distribution of primary health care facilities and their status (old, new, upgraded, under construction, renovated and equipped), and the service provided, including essential surgical services. Results: Of 5072 (518 are Health Centers and 4554 are Dispensaries) existing public primary health care facilities, the majority (46%) had a physical status of A (good state), 33% (1693) had physical status of B (minor renovation needed) and the remaining facilities had physical status of C up to F (needing major renovation). About 33% (1673) of all health facilities had piped water and 5.1% had landline telecommunication system. Between 2015 and August 2019, a total of 419 (8.3%) health facilities (Consisting of 350 health centers and 69 District Council Hospitals) were either renovated or constructed and equipped to offer safe surgery services. Of all Health Centers only 115 (22.2%) were offering the CEMONC services. Of these 115 health facilities, only 20 (17.4%) were offering the CEMONC services with all 9-signal functions and only 17.4% had facilities that are offering safe blood transfusion services. Conclusion: This study indicates that between 2015 and 2019 there has been improvement in physical status of primary health facilities as a result constructions, upgrading and equipping the facilities to offer safe surgery and related diagnostic services. Despite the achievements, still there is a high demand for good physical statuses and functioning of primary health facilities with capacity to offer essential and safe surgical services in the country also as an important strategy towards achieving UHC. This is also inline with the National Surgical, Obstetrics and Anesthesia plan (NSOAP).
Located in East Africa, Tanzania has an estimated area of 945,087 km2 and a population projection (2019) of 55,890,747 (Male 27, 356,189 and Female 28,534,558). While 29.6% of the population lives in urban areas, 70.4% resides in rural localities. About 50.1% of the population is below 18 years of age, 16.2% of the population aged 5 or under, and 5.6% is aged 60 years and above [31]. As of 2019, there are 12,545 villages, 4420 Wards, 26 regions and 185 district councils in the country [31]. The health system in Tanzania operates in a decentralized system. The health care referral system is organized in a pyramid structure. At the base of the pyramid is the community, followed by dispensary, health centers and District Hospitals that constitute the primary health care. These are followed by district hospitals or designated district hospitals that are then followed by regional referral hospitals, zonal hospitals, specialized hospitals and finally the National Hospital. By December 2015, there were a total of 6640 (53%) dispensaries out of 12,545 villages (The Tanzanian policy is to have a Dispensary for every Village), of which 4554 (36%) are government owned. There are a total of 695 (15.7%) health centers out of 4420 Wards (Tanzanian policy is to have a Health Center for every Ward), of which 513 (11.6%) are government owned (Table 2). The formal distinction between dispensaries and health centers is that while dispensaries exclusively provide outpatient care, a health center should be able to provide around-the-clock care to patient and also surgical services including emergence obstetric care. The Skilled Human Resources for health gap in the health care system stands at 52% [21]. Distribution of health facilities by type and ownership by December 2015 Infrastructure development at primary health care is coordinated by the Local Governments Authorities (LGAs) with collaboration with the local community. The central ministries (Ministry of Health and President’s Office – Regional Administration and Local Government) are responsible with provision of guidance on the building standards, structure, and equipment and provide funds for renovations of existing facilities and construction of new facilities. Currently there are about 1845 unfinished buildings of primary health care facilities in the country. This study relied on a cross-sectional analysis of data collected from public primary health facilities from all over the country from 2005 to 2019 as part of routine national health information on health care infrastructure and associated strategies and plans. In order to systematically appraise the processes behind the contemporary health facility improvement program of which the information analyzed in this study are based, the study was build on the following activities 1) Understanding the theory of change of the program 2) understanding the methods adopted in improving the health facilities (constructions and renovations), 3) Understanding the related reforms at various levels to support the program 4) Description of the data collection procedures and tools 5) conducting analysis of the gathered data. Developing the theory of change (TOC) or a program theory is the first prerequisite in understanding the implementation processes and effects for any program [32]. The TOC helps to establish potential causal pathways between the primary health care development program (PHCDP) inputs and the expected outcomes that in this case is reduction in morbidity and mortality through administration of the safe surgeries. A theory of change for the extension of the Primary Health Care Development Programme (PHCDP) was conceptualized during two stakeholder meetings that included the health basket fund: during the RMOs and DMOs meeting in October 2016 and during the conclusion of the joint visit between PORALG and MoHCDGEC in December 2016 [25]. During these meetings, participants articulated the processes of change they anticipated. The authors of this paper further refined the ToC to be utilized in the prospective evaluations, based on a review of the literature (Fig. 1). Therefore, this documentation study was done so that to help understand the progress and achievement made in terms of primary health care facilities in Tanzania as an important step in the provision of safe surgeries hence reduction in surgeries related morbidities and mortalities as well as other disease conditions. Theory of Change for infrastructure development of public primary health facilities in Tanzania The construction of primary health facilities that was done between January 2017 and November 2019 used force account for renovation and construction with great success. District Councils were able to procure building materials and/or engage temporary labor to carry out the work. To reduce costs and enhance community ownership, local artisans were sub-contracted by the district to renovate the buildings. District engineers were responsible for carrying out supervisions to the renovation and construction sites. Upon receipt of funds from the central government through the Ministry of Finance and Planning, three local construction or renovation committees were created by the district were: procurement, construction as well as receipt and inspection committees. The district used the following criteria for selecting facilities for renovation: 1) A distance from the district head office of more than 20 km, 2) Health facilities with physical state designations of B, C, E or F (Table 3), meaning major or minor renovation was needed or the facility was under construction or renovation, 3) An area with a catchment population of more than 10,000 people and 4) A health center with no operating theatre. Building renovations were performed on: roofing; windows and doors; floors and ceilings; as well as plumbing, electrical, sewage, solid waste management, and water harvesting systems. In each of the district council in Tanzania, in addition to renovation, six buildings were constructed on site, including a maternity ward, outpatient department (OPD), laboratory, operating theatre, mortuary and laundry by using a force account which it has shown to be a game changer. Infrastructure elements Equipment • Building or infrastructure repair • Equipment processing Infection control • Availability of infection control items • Adequate disposal system for infectious waste Availability of soap, running water, sharp box, latex gloves and disinfectant Collection of disposal of infectious waste No unprotected waste observed Presence of ambulances Presence of a reliable means of communication Less than 10 km Between 5 km -10kms More than 10 kms The LGAs are responsible for management and implementation of the renovation and infrastructural development program. Their responsibilities also include provision of technical support to lower levels, mainly wards and villages. The Ward Development Committees (WDC) and Village Governments (VG) are responsible for coordinating and supervising the various activities carried out at these levels. They are also responsible for mobilization of the community for their active participation and for daily supervision of ongoing projects and punishment of the local artisans. In addition, the Council Health Service Boards and Health Facility Governing Committees work together with specified committees (construction, procurement and inspection committees) to enhance accountability and governance. This program was financed from different sources within the Government of Tanzania and its implementing partners through the health basket fund. Heath Basket fund has been supporting health sector in Tanzania since the year 1999/2000, it is part of the government effort to implement a Sector Wide approach (SWAp) arrangement whereby different development partners puts their contributions into one basket and then support the health sector through 13 priority areas as spelled out in the Comprehensive Council Health Plan (CCHP) and Comprehensive Health Plans guidelines [33]. The health basket fund is considered to be one of the reliable sources of funds in the country. The release of these funds is guided by signing of the side agreements after mutual agreement between Health Basket Financing partner and Government of Tanzania and it is part of implementation of the five-year’s Memorandum of Understanding (MoU) [34]. For each healthcare facility, a total of TZS 700,000,000 (305,650.16 USD) was put aside to renovate health facilities of which TZS 500,000,000 (218,321.54 USD) was used for construction of 5 to 6 buildings (operating theatre, maternity block, laboratory, mortuary, staff building, incinerator and placenta pit) as well as waste management infrastructure and 200,000,000 (87,328.62 USD) for medical equipment (Exchange rate 1 USD = 2290.20 TZS as of 07.11.2018). In 2017 the Government of Tanzania embarked on the Direct Health Facility Financing (DHFF) program with hypothesis that the program would increase provider autonomy over access to and use of resources, increase the engagement of health facility governing committees (HFGC) in the planning and financing of care, and result in the improved structural quality of care as facility resources were directly invested in service delivery [32]. Therefore, DHFF program was designed to help procure resources for renovation and maintenance of physical infrastructures at the local level and also increase accountability and value for money for all projects [32]. Since inception of construction and renovation of health facilities the DHFF program has been used as an approach for quick and reliable disbursement of funds for construction/renovation. In the financial year 2017/2018, the Government of Tanzania introduced a new financial mechanism that differed slightly from the traditional financial mechanism in which finances were channeled through district offices and then went to the primary healthcare facilities. In the new approach, DHFF funds go directly from the treasury to the primary health facility, which has helped to greatly reduce bureaucracy [32]. The system has also enhanced primary health facility autonomy, including over the planning and budgeting for health facilities, allowing them to make decisions regarding infrastructure development and renovations [33]. Data related to infrastructure development in the primary health facilities were collected from the following sources Construction and upgrading of dispensary and health center buildings by using force accounts, up to August 2019 aConstruction of health centers, outpatient departments, operating theatres, laboratories, pediatric and maternity wards, as well as waste management facilities like incinerators and placenta pits In this study, the variables of interest were: Health facility status variables which included: 1) Type of a health facility, categorized into dispensary and health center 2) Distance of the health facility from district headquarters was measured in kilometers 3) years of operation was measured years and categorized in 5 years intervals 4) Training status on maternal health and safe surgeries 5) Physical status of the facility categorized into A to F 6) location of the health facility measured as urban or rural. CEMONC services data: measured in relation to presence or absence of CEMONC services Amenities in health facilities; the amenities were divided into physical utilities and waste management equipment. In this category variables were measured into yes or not in relation to availability of a given amenity. The amenities studies include: Water 2) Electricity 3) Phone 4) incinerator 5) Placenta and 6) Waste bin. We used MS Excel spread sheet (Microsoft Excel®, Microsoft Corporation) to manage the collected data and thereafter imported to Statistical Package for social science (SPPS) program version 22 (SPSS Inc., Chicago, IL, USA) for further analysis. Descriptive statistics were used to summarize data, some of them where frequencies, percentages and then followed by inferential statistics by using a chi-square and bivariate analysis to determine relationship between variables and location of the health facility (rural vs urban).
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