General_Information_PS3.docx

THE PUBLIC SECTOR SYSTEMS STRENGTHENING (PS3)

(Sections Background, Scope and Performance Areas) Background Socio-Economic Context Ranked among the world’s top 30 fastest growing economies,[footnoteRef:1] Tanzania has experienced considerable economic growth over the past decade, averaging seven percent per year. As stated in the Tanzania Development Vision 2025 and MKUKUTA II,[footnoteRef:2] the nation’s long term plan is to achieve middle-income country status by 2025. [1: IMF World Economic Outlook Database] [2: Also known as the National Strategy for Growth and Reduction of Poverty (NSGRP), a 5-year strategic plan aimed at accelerating economic growth, poverty reduction, improving governance, and the achievement of the Millennium Development Goals (MDGs). ]

While economic growth efforts are important for achieving middle-income status, Tanzania experiences critical vulnerabilities that may impede achievement of broader development targets. Specifically, the country has 1) a large (45 million) and rapidly growing population (2.7% per annum) based mainly in rural areas, 2) significant poverty levels (28.2% of the population living below the basic needs poverty line)[footnoteRef:3], 3) considerable inequities in access to basic services, 4) high youth unemployment (accounting for 33% of the unemployed),[footnoteRef:4] and 5) numerous pressing health concerns. Addressing these issues, concurrently with the nation’s focus on economic growth, will be critical to reaping the benefits of the demographic dividend. Specific key health and social issues include: [3: Tanzania Household Budget Survey 2011/2012. National Bureau of Statistics – Reference ID TZA-NBS-HBS-2013 - www.nbs.go.tz] [4: Integrated Labor Force Survey 2006. National Bureau of Statistics – Reference ID TZA-NBS-ILFS-2006-v01.]

· Maternal Health: Maternal Mortality is considerable at 454 deaths per 100,000 live births.[footnoteRef:5] Only half of women deliver in a health facility. Low availability of emergency obstetric and new born care services, chronic shortage of skilled health providers and a weak referral system also contribute to the high number of maternal deaths.[footnoteRef:6] [5: National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2011. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro.] [6: UNICEF Maternal and Child Health Overview for Tanzania http://www.unicef.org/tanzania/6906_10741.html]

· Child health: Tanzania’s infant mortality rate is 45 deaths per 1,000 live births,[footnoteRef:7] while the under-five mortality rate is 68 deaths per 1,000 children.[footnoteRef:8] Although under-five deaths have dropped, recent care-seeking behavior for the major killers of children under five (pneumonia, malaria, and diarrhea) is low and has been attributed to poor quality of health services.[footnoteRef:9] [7: World Health Statistics 2013. World Health Organization.] [8: World Health Statistics 2013. World Health Organization. ] [9: Ministry of Health and Social Welfare. 2013. Mid-term review of the Health Sector Strategic Plan III. UNICEF Maternal and Child Health Overview for Tanzania]

· HIV/AIDS: Mainland Tanzania has an estimated adult prevalence of 5.3%.[footnoteRef:10] As of December 2013, Tanzania has an estimated 1.4 million people infected with the disease[footnoteRef:11], That said, Tanzania has seen a growing number of people with HIV/AIDS receiving treatment for the disease, with over 500,000 people currently receiving treatment[footnoteRef:12]. [10: Tanzania Commission for AIDS (TACAIDS, Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF International. 2013. Tanzania HIV/AIDS and Malaria Indicator Survey 2011-12. Dar es Salaam, Tanzania: TACAIDS, ZAC, NBS, OCGS, and ICF international. ] [11: www.UNAIDS.org - Global AIDS Response Progress country report, March 31, 2014] [12: Document available upon request to the National AIDS Control Programme (NACP)]

· Malaria: Between 60,000 to 80,000 people die from malaria each year on the Mainland. Approximately 10 to 12 million clinical malaria cases are reported each year, and more than 40% of all health visits are attributed to malaria.[footnoteRef:13] [13: President’s Malaria Initiative, Tanzania http://pmi.gov/countries/profiles/tanzania.html]

· Tuberculosis (TB): Tanzania has one of the highest TB burdens worldwide, and TB remains the leading cause of disease burden and deaths in people living with HIV/AIDS.

· Family Planning: On average, Tanzanian women have 5.4 children, and the unmet need for family planning is considerable at 25% of married women.[footnoteRef:14] [14: National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2011 Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro]

· Nutrition: Prevalence of childhood stunting in Tanzania is currently 47%, with similarly high levels of maternal anemia. [footnoteRef:15] [15: National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2011 Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro]

· Education: The majority of Tanzania’s primary school children cannot read with comprehension and lack the foundational skills for lifelong learning and success.

· Agriculture: This sector employs 74% of Tanzania labor force, yet most are women subsistence small-holder farmers who lack access to markets. [footnoteRef:16] [16: Tanzania Household Budget Survey 2011/2012. National Bureau of Statistics – Reference ID TZA-NBS-HBS-2013 - www.nbs.go.tz]

Most of the issues mentioned above are derived from weak country systems. The public sector is the key stakeholder of these country systems and a critical player in economic growth efforts.

Local Government Capacity For Service Delivery The public sector serves as an important steward over economic growth efforts. To facilitate this process and to strengthen governance, the GOT adopted a “Decentralization by Devolution” process under the Local Government Reform Act of 1996 and has moved many planning and budgetary responsibilities for service delivery from the central level to 161 districts. However, considerable challenges remain at the district level to meet the needs of Tanzanians, particularly the rural poor. These include --

· Inadequate financing for critical functions to provide quality assurance of services

· Incomplete decentralization of some core functions thereby weakening district empowerment

· Insufficient coordination and involvement of district stakeholders (i.e multiple line ministries, non-governmental organizations (NGOs), civil society and private entities) leading to fragmentation and duplication

· Lack of clarity on roles, responsibilities, and communication channels

· Paucity of mechanisms to receive and respond to client concerns

· Weak planning and management capacities

· Few internal controls and awareness of best practices for financial management USAID/Tanzania Country Development Cooperation Strategy and Cross Sector Links To holistically address and strengthen country support needs, USAID/Tanzania’s activities are influenced by its new Country Development Cooperation Strategy (CDCS) and cross sector links to promote a multi-sectoral approach to activities where strategic and feasible. As such, USAID/Tanzania leadership values integrated programming. PS3 is strongly aligned with the new CDCS framework and contributes to all development objectives and Intermediate Results (IR), particularly to IRs in DO3 as well as IR 1.2 in DO1.

Cross-Cutting IR: Data-driven decision-making and action plan implementation improved

As shown above, USAID recognizes the complexity of multi-dimensional development challenges and the value of addressing them using multiple perspectives and tools across sectors. In this respect, the CDCS calls for a strategic approach to systems strengthening inclusive of sectoral specific and multi-sectoral approaches. As such, the PS3, while it is primarily focused on health sector system strengthening, will also strengthen systems at the local level extending beyond the health sector.

In recognition of this approach, USAID Tanzania’s Economic Growth; Democracy, Human Rights, and Governance (DRG); and Education programs have a vested interest in this Activity. PS3 will leverage synergies within multiple Mission programs facing similar system challenges at the district level to address the following issues:

· Inclusive Economic Growth: PS3 will strengthen the capacity of Local Government Authorities (LGAs) to budget, procure, financially manage, and account for their funds – systems which are critical to all services rendered by LGAs, including LGA maintenance of road networks that are essential to advancing Tanzania’s rural and agriculture-based economy. Poor rural roads inhibit the flow of all economic goods, greatly increasing costs for the consumer and limiting Tanzania’s competitiveness in regional markets. The Feed the Future Initiative supports roads and infrastructure activities through Government-to-Government arrangements that call for strong financial management capacities at the district level. In addition, PS3 will support LGAs to better identify, assess, and develop new options for local own source revenue (LOSR) that are transparent and do not dis-incentivize investment and agricultural production.

· DRG: PS3 aims to strengthen target LGAs by improving financial management, local revenue collection and management, and use of data in planning and monitoring. In addition, DRG investment supports the strengthening (or creating where necessary) mechanisms for civic oversight and accountability, including oversight of LGA implementation of audit recommendations.

· Education: PS3 will build the capacity of LGAs to use data from district human resource information systems to inform workforce-planning decisions, particularly as it relates to reducing teacher staffing shortages in rural areas. By strengthening human resource management capacities at the district level, USAID/Tanzania’s Education program aims to facilitate a more equitable distribution and supervision of teachers across schools.

Given both its health and multi-sectoral emphasis, PS3 includes a strong operational research component to monitor and demonstrate relevance, causal-link, and impact of PS3 on USAID priority health areas (maternal and child health, malaria, TB, family planning, nutrition, and HIV/AIDS) in addition to cross-cutting and holistic results at the local government level pertinent to health, education, agriculture, rural roads, and water and sanitation sectors.

Relationship of Ps3 to Usaid/Tanzania’s Global Health Initiative Strategy[footnoteRef:17] [17: Tanzania Global Health Initiative Strategy 2010-2015. USAID / Tanzania, Dar es Salaam. For more information, please see http://www.ghi.gov/whereWeWork/docs/TanzaniaStrategy.pdf]

In addition to the CDCS, PS3 is guided by USAID/Tanzania’s Global Health Initiative (GHI) Strategy. PS3 falls within GHI’s intermediate result two (IR2) of the GHI strategy-improved health systems to strengthen the delivery of healthcare services. It will also contribute towards the achievement and long term sustainability of the two other objectives: Intermediate result one (IR1) - increased access to quality integrated services with focus on maternal, neonatal and child health; family planning and reproductive health; and intermediate result three (IR3) - improved adoption of healthy behaviors- including health care seeking behaviors – with a focus on women and girls. Together, USAID/Tanzania’s health activities will support the GOT and its partners towards developing Tanzania’s social and economic status.

Relationship of Ps3 to USAID/Tanzania’s Health Systems Strengthening (HSS) Approach As mentioned above, Health Systems Strengthening (HSS) is a key intermediate result of the GHI, and achievement of this result is guided by the Mission’s HSS strategy (2013).[footnoteRef:18] PS3 is a critical contributor to the implementation of this strategy. [18: Available on the USAID’s Clearing House (dec.usaid.gov); Document ID - 8311bc55-9259-449e-b368-c21af084503a]

Per the Strategy, PS3 will target improvements in Tanzania’s health systems that are sustainable after donor support ends, including institutionalized capacity for ongoing improvement. As such, it is expected that the country will increasingly rely on its own financial resources and have the human resources and institutional capacity to sustain and improve health services for all of its citizens.

PS3 will support the HSS Strategy using the following underlying approaches:

· An integrated response[footnoteRef:19] across the World Health Organization (WHO) health system ‘building blocks’[footnoteRef:20] (i.e. service delivery, health workforce, information, commodities, financing, leadership and governance) [19: Reference: Don de Savigny and Taghreed Adam, Eds. Systems Thinking for Health Systems Strengthening. Geneva: Alliance for Health Policy and Systems Research and World Health Organization, 2009.] [20: The WHO building blocks for the health system comprise of 1) Health Finance, 2) Governance, 3) Human resources, 4) Information, 5) Medical Products, Vaccines and Technologies, and 6) Service Delivery.]

· Prioritization of long-term sustainable ‘strengthening’ interventions over stop gap/‘support’ measures[footnoteRef:21] [21: Chee G., N Pielemeier, A Lion, C Connor. 2013. ‘‘Why differentiating between health system support and health system strengthening is needed?’ International Journal of Health Planning and Management: 28(1):85-94.]

· Increased leveraging of multiple funding sources e.g. the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI) to support a more strategic and purposeful portfolio that helps address the major weaknesses in Public Sector Systems Strengthening

· Added emphasis on monitoring and evaluation of activities to inform programming and document outcomes relevant to both the overall system strengthening and to specific priority areas.

· Greater leveraging, partnering, and liaising with a variety of stakeholders

In addition to the USAID/Tanzania Health Systems Strengthening Strategy, the Midterm Review of the Health Sector Strategic Plan III provides detailed background on current issues facing the Tanzanian health care system. [text will be inserted]

Critical Assumptions PS3 assumes a continued commitment in the following policy and institutional areas at both the national and LGA levels:

· Political will and commitment to implement necessary policy changes and public sector systems strengthening

· The GOT will continue to experience economic growth rates that can potentially be leveraged to sustainably finance healthcare and other critical services

· The GOT possesses political will to implement a comprehensive health financing strategy

· GOT possesses political will to improve administration of local taxes

· The GOT continues to invest in attracting and retaining a skilled workforce

· The GOT and stakeholders desire an integrated health information system

· The GOT policy agenda and its implementation will focus on addressing the most binding constraints to growth in order to unleash Tanzania’s potential to advance inclusive broad-based economic growth and reduce poverty.

Scope

The Public Sector Systems Strengthening (PS3) activity will have a five year period of performance. The Contractor will support the Government of Tanzania (GOT) to strengthen the public system to promote the delivery, quality, and use of services, particularly for underserved populations. In so doing, The Contractor will strengthen overall health care systems, inclusive of GOT and USAID priority programs. Furthermore, the Contractor will strengthen key multi-sectoral components of LGA systems as part of the approach to promote inclusive and evidenced-based planning, management, and implementation of services.

The Contractor will use an integrated approach across the World Health Organization’s (WHO) systems’ building blocks[footnoteRef:22] of governance, financing, human resources, and information to strengthen health systems at the national level, while simultaneously building these capacities at the LGA level to improve service delivery and planning across all sectors. The Contractor will work with the following key GOT entities at a minimum: [22: The WHO building blocks for the health system comprise of 1) Health Finance, 2) Governance, 3) Human resources, 4) Information, 5) Medical Products, Vaccines and Technologies, and 6) Service Delivery.]

· Ministry of Health and Social Welfare (MOHSW)

· Prime Minister’s Office – Regional Authority for Local Government (PMO-RALG)

· President’s Office - Public Service Commission (PO-PSM)

· Ministry of Finance (MOF) As a part of the operational research component, the Contractor will demonstrate relevance, causal-link, and impact of the program on USAID priority health areas to include maternal and child health, malaria, TB, family planning, nutrition, and HIV/AIDS in addition to cross-cutting and holistic results at the local government level pertinent to the health, education, and agriculture sectors. As such, PS3 will include a robust learning agenda to define and track indicators needed to guide contract implementation and to continually measure if systems are being strengthened and results are being achieved.

The Contractor must support the GOT needs at both the national and local government authority (LGA) levels.

National level efforts will focus on informing the development and operationalization of key strategies, policies, and guidance to include the National Health Care Financing Strategy, Health Sector Strategic Plan IV, Human Resources for Health Strategy, the Social Welfare strategy, and e-Health Strategy. Local government-level efforts will focus on translating national guidance into action, while informing the national dialogue based on LGA-level realities on the ground. Furthermore, the Contractor will accommodate the multi-sectoral nature of LGAs, where relevant and appropriate, to promote inclusive and evidenced-based planning, management, and implementation of services.

To the maximum extent feasible, the Contractor will work within government systems, and must engage citizens to participate in improving system accountability to achieve the targeted results. The Contractor will work in close coordination with civil society and related national and local programs (including those supported by the U.S. Government (USG), Development Partners (DPs), the GOT, and/or civil society) to enhance the impact of PS3 investments.

PS3 will operate at a national level, as well as in all districts of 13 targeted Tanzania Mainland regions. The Contractor must support the following five PS3 components. Components 1-4 will be fully integrated, with the LOE of each component dependent on the needs of each government authority. Operations research will not exceed 10% LOE.

The Contractor must support the strengthening of GOT systems at the national and LGA level across all components and in alignment with GOT priorities for improving systems. The Contractor must engage with MOHSW, PMO-RALG, PO-PSM and MOF at the national level and additional entities, as required, addressing gaps identified during PS3 implementation. At the LGA level, the Contractor will engage with all relevant stakeholders to include civil society and individual citizens as defined by the five components within the purview of the District Executive Director and the Council Chairman. Additionally, the Contractor will examine existing mechanisms of the Government for obtaining and considering civil society and citizens’ input strengthening and supporting the implementation. The Contractor must target systems strengthening interventions and approaches that contribute to improved and sustainable systems performance that will last beyond PS3 implementation.

In addition to cross-sectoral system strengthening, the Contractor will support the GOT to strengthen the overall health care system. The health system includes: public, faith-based, and private sector health providers, as these entities fall within the purview of the GOT’s stewardship and coordination function.

Performance Areas

At the local government level, the Contractor must cover all LGAs (currently 63) in the following 13 target regions of the Tanzania Mainland: Dodoma, Iringa, Kagera, Kigoma, Lindi, Mara, Mbeya, Morogoro, Mtwara, Mwanza, Njombe, Rukwa, and Shinyanga. These regions have been selected based on the following criteria.

· Location of current USAID programming efforts: Specifically, those relating to USAID’s democracy and governance program, Feed the Future Initiative, Education USAID’s health program, including recent HSS local government targeted efforts in governance, human resources for health (HRH), and financial management.

· Location of donor partner programming for HSS activities: Specifically, those relating to supportive supervision, governance, health management information systems, community health fund, public private partnerships and results based financing initiatives.

· Areas of highest burden of disease: Namely, contraceptive prevalence, stunting, HIV prevalence and malaria prevalence.

· LGAs with low performance on HSS indicators: Specifically, the percent of planned activities executed per the LGA comprehensive council health plan, gaps in the establishment of potential public private partnerships, per capita personnel expenditures, per capita other charges expenditures, the number of nurses per 1,000 population.

While all current 63[footnoteRef:23] LGAs are expected to be eligible to receive some level of PS3 support, it is anticipated different levels of LGA support will be provided based a competitive selection process Prior to the selection of the LGAs, the Contractor must develop a robust and transparent two phased competitive selection approach and criteria to determine which district will receive a more robust package of PS3 support (Phase 1) compare to those districts which will receive a minimum package of PS3 support (Phase 2). Prioritized LGAs for the more robust package need to be responsive, motivated and willing to receive PS3 support. PS3 must offer all LGAs a minimum of three (3) years support. The approach, final selection criteria and number of LGAs for both phases will be submitted by the Contractor in its first year work plan for approval by USAID in coordination with GOT. [23: Currently there are 63 LGA, however contractor must plan for changes in this number that may occur and must be ready to accommodate changes at any time during the course of the award

DO 1

Tanzanian women and youth empowered

DO 2

Inclusive broad-based economic growth sustained

DO 3

Effective democratic governance improved

IR 1.2

Health status improved

IR 1.3

Lifelong learning skills improved

IR 2.1

Binding constraints to private sector investment reduced

IR 2.2

Agricultural productivity and profitability increased in targeted value chains

IR 2.3

Stewardship of natural resources improved

IR 2.4

Unmet needs for family planning reduced

IR 3.1

Citizen engagement made more effective

IR 3.2

Government delivery of services improved

IR 3.3

Government accountability increased

IR 1.1

Gender equality increased

GOAL

Tanzania’s socio-economic transformation toward middle income status by 2025 advanced image1.png image2.png image3.png image4.png