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.

Jennifer J Palmer,Alice Gilbert,Michelle Choy,Karl Blanchet

doi:10.1186/s12961-016-0137-9

Abstract

BackgroundLittle 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.MethodsIn 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.ResultsPractitioners 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.ConclusionsHealth 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 materialThe online version of this article (doi:10.1186/s12961-016-0137-9) contains supplementary material, which is available to authorized users.

Highlights

Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa
Setting and selection of study sites The ‘Lake Region’1 of north-west Tanzania, where this study was conducted, has far fewer human resources for eye health and performs less cataract surgeries than recommended for sub-Saharan Africa (0.2 ophthalmologists per million population compared to a target of 4.0; 6.1 mid-level personnel including Assistant medical officer in ophthalmology (AMOO) and nurses compared to the 10.0 target; 1.4 optometrists compared to a 20.0 target; data collected from districts by study team, see [11])
These deficiencies subsequently compromised implementation of Tanzania’s domestic eye health strategies. This was seen as a problem of global and domestic health priorities: by not directly causing mortality, vision loss could not compete with interventions for maternal-child health and HIV prioritised by the Millennium Development Goals, which play a key role in framing the health strategy in Tanzania

Summary

Introduction

Little is known about the contributions of faith-based organisations (FBOs) to health systems in Africa. Christian missions were the cornerstone for the promotion of Western-style health, education and wealth Today, they derive much of their legitimacy as organisations capable of reaching the ‘grass roots’ with their continued relevance attributed to the failures of the African State to deliver services and engage holistically with poor peoples’ needs [1]. They derive much of their legitimacy as organisations capable of reaching the ‘grass roots’ with their continued relevance attributed to the failures of the African State to deliver services and engage holistically with poor peoples’ needs [1] This contribution is widely acknowledged in high-level global health policy dialogue and practice, for example, through the awarding of large development grants to Christian FBOs by major donors [2]. Surprisingly little is known about the comparative benefits, harms and contributions of faith-based, non-state actors alongside government providers in achieving the basics of universal health coverage (health system reach to poor people, cost to patients and satisfaction of patients with services) or the sustainable health system governance that supports this [2,3,4,5]

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Results

Discussion

Conclusion