Building a responsive and resilient health system in Tanzania: exploring recommendations from literature and the first International Primary Health Care (iPHC) conference

¹Department of Health Social Welfare and Nutrition Services, President's Office Regional Administration and Local Government, Dodoma, Tanzania, ²Department of Public Health, University of Dodoma, Dodoma, Tanzania, ³Ministry of Health, Dodoma, Tanzania, ⁴Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, ⁵Dar es Salaam City Council, Dar es Salaam, Tanzania, ⁶Centre for Education Development for Health, Arusha, Tanzania, ⁷School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania, ⁸Mathematics Department, University of Dar es Salaam, Dar es Salaam, Tanzania, ⁹East, Central and Southern Africa - Health Community (ECSA - HC), Arusha, Tanzana, ¹⁰Center for Reforms, Innovation, Health Policies and Implementation Research (CeRIHI), ¹¹Department of Public Health, St Francis University College of Health and Allied Sciences, Ifakara, Tanzania

^&Corresponding author
James Tumaini Kengia, Department of Health Social Welfare and Nutrition Services, President's Office Regional Administration and Local Government, Dodoma, Tanzania

Introduction    

Achieving Universal Health Coverage (UHC) is one of the main targets of the 2030 Agenda for Sustainable Development, under goal number 3 [1]. In the stride towards attainment of UHC goals, dedicated efforts to strengthen the functionality of health systems, in particular Primary Health Care (PHC), play a pivotal role [2]. In order to guarantee attainment of equitable and sustainable health outcomes and to improve the well-being of individuals in the community and population at large, strategic and operational investment in the health system is inevitable [3]. Universal Health Coverage (UHC) entails addressing both supply and demand side health system bottlenecks with ultimate goals towards improving people´s health and well-being, responding to people´s expectations, and providing protection against the costs of ill-health [4].

In the Tanzanian context, addressing the unfinished agenda related to health system strengthening is imperative. Key issues that need attention include: improving the quality of care, integration of health services, strengthen capability for the provision of early diagnosis and treatment to non-communicable diseases (NCDs), palliative and rehabilitative care. Moreover, improving promotive and preventive health services, data use for decision-making, insurance coverage, staffing, strengthening governance, leadership, and intersectoral coordination are critical for a resilient and responsive health system [5]. Furthermore, in building a resilient health system availability of real-time data for surveillance, community readiness in responding to emerging and re-emerging diseases, addressing existing gaps in beyond health system building blocks areas such as community health system, climate change, commercialization of unhealthy food products, and social determinants of health [6,7] is inevitable. To attain the intended goals and fix the bottlenecks within the health system, investment in PHC is an important entry point and is seen as a quick win towards strengthening the health system for UHC and attainment of SDGs related to health [8,9]. Addressing the unfinished agenda and the implementation of regional and global-level agreements and treaties geared towards making PHC strong, resilient, and responsive is critical for the future of PHC in Tanzania.

To provide a platform for sharing and generate evidence to inform PHC system strengthening efforts, the Government of Tanzania launched the 1^st International Primary Health Care Conference (iPHC) in March 2023. This conference served as a platform for various stakeholders with different backgrounds, from local and international, to share, analyze, and discuss existing local and international evidence, activities, and strategies to improve PHC. The conference was attended by around 1862 delegates from within Tanzania and international experts with an interest in PHC and UHC at large. Recently, there has been an effort to document the unfinished agenda to build a responsive and resilient PHC system in Tanzania [5]. The current work provides additional evidence synthesis of information gathered during the 1^stInternational Primary Health Care Conference in Tanzania, literature review, and discussions on lessons learned in the field to inform new practice, policy, and new research areas towards strengthening PHC in Tanzania.

The objective of this work is therefore three-fold: i) To explore unfinished agenda in health system strengthening across WHO health system building blocks and beyond; 2) To explore health system strengthening innovations and or recommendations across WHO health system building blocks and beyond; 3) To provide a structured synthesis of lessons learned to guide efforts in strengthening the PHC system.

Methods     

Country context

Located in East Africa, Tanzania has a population of 61.7 million people with a population growth rate of 3%. It is considered a lower middle-income country by the World Bank since July 2021with a GDP of U$ 62. million and a GNI per capita of U$ 1,140. The poverty rate in Tanzania stands at 33.4% and the country´s capacity to collect taxes remains low and hence depends on donor funding of about 29% of the total country budget. The Government of Tanzania (GoT) has made significant progress in fulfilling its population health demands despite many obstacles encountered in the implementation of interventions. The life expectancy at birth (years) has improved by 14.3 years from 52.5 years in 2000 to 66.8 years in 2021 [10]. The Government of Tanzania has made substantial efforts in health care system strengthening in different areas, including innovations in digital health and service delivery. The GoT has deployed a digitalized system (Government of Tanzania Health Operations Management Information System (GoT-HOMIS), District Health Information System (DHIS 2), Facility Financial Accounting and Reporting System (FFARS), and Government Electronic Payment Gateway (GEPG) all of which increase efficiency and effectiveness of operations within PHC facilities. With the improvements in the digitalized system, the GoT's current efforts are directed towards integration of the digital system to ensure continuum of care and data exchange [11].

Apart from digital health reforms, the implementation of Direct Health Facility health financing in primary health care settings has increased accountability, responsibility, and effective resource mobilization in primary health care settings [12,13]. The GoT has also undertaken measures to ensure the availability of health commodities in sufficient amounts by increasing the budget for health commodities. For example, in the year 2020/2021, the allocated budget for medical commodities was 230 billion compared to 30 billion in the year 2015/2016, and for the same period, the number of skilled health care workers increased from 86,152 to 102,469 [13]. The health sector in Tanzania, however, still faces a shortage of staff, with data by 2023 showing the availability of 1 doctor per 8,882 population and 1 nurse per 1,289 population. This represents 8.89 doctors and nurses per 10,000 population, which is significantly less than the WHO recommendation of 22.8 doctors, nurses, and midwives per 10,000 population.

To optimize the efficiency and effectiveness in the utilization of available human resources for the health workforce, more efforts are directed to strengthen e-learning platforms, incorporating current demand needs to professional curriculums, conducting on job trainings, and ongoing capacity building for the healthcare workers workforce [14]. The GoT has also made massive improvements in the availability of health facilities and infrastructure, fueled by a dedicated investment plan that started in 2017. This plan involved the construction and rehabilitation of dispensaries, health centers, and council hospitals. To date, there are, 7315 dispensaries, 979 health centers, and 189 council hospitals. Compared to 4,127 dispensaries, 535 health centers, and 77 council hospitals that were available in 2015.

The first iPHC Conference in Tanzania

The International Conference on Primary Healthcare in Tanzania was held in Dodoma from 25^th to 27^th March 2024 at the Jakaya Mrisho Kikwete Convention Center. It was designed to provide an avenue for local and international actors to share experiences from the field, documented success stories, and strategize for the unfinished agenda in PHC. The main theme of the conference was "Primary Healthcare (PHC) as a Vehicle for Achieving Universal Health Coverage (UHC) in Tanzania," This theme was chosen purposely to reflect the current global move towards UHC. The conference was coordinated by The President's Office, Regional Administration, and Local Government (PORALG) in Tanzania, whose core functions, among others, is coordination of different stakeholders in improving health services at the primary health settings, thus the iPHC conference is a great platform to showcase and discuss different scientific works in PHC settings. The conference assembled around 1,862 participants, encompassing local and international primary healthcare experts (Figure 1), government leaders, representatives from humanitarian organizations, local and International Non-Governmental Organization, UN Agencies, Regional Health Bodies and other key stakeholders within the healthcare sector. Over the course of the conference, 17 forums were conducted on various topics, emphasizing access to primary healthcare, service quality, disease prevention and control, community engagement, innovation in health care financing, role of research, challenges in service delivery, and strategic solutions to these challenges.

A substantial number of scientific contributions were made during the conference, with 290 abstracts received. Of these, 145 were accepted, leading to 129 presentations and the publication of 112 abstracts. These scientific presentations highlighted innovative research and findings from primary healthcare facilities, contributing significantly to improving primary healthcare services in Tanzania and adding to the global knowledge base. The conference provided an excellent platform for showcasing and deliberating on scientific work in primary healthcare settings, underscoring PORALG´s commitment to improving healthcare delivery. The conference aimed to achieve the following key objectives; 1) Advocacy of scientific findings: to discuss and promote scientific findings from research and studies conducted at primary healthcare facilities, with a focus on improving service provision, 2) Promotion of preventive services: to enhance public health by advocating for health promotion and preventive services, 3) Collaboration and networking: to establish and strengthen collaboration between domestic and international stakeholders, ensuring a unified effort in combating diseases, 4) Capacity building: to establish an international platform for sharing updated knowledge and expertise towards improving PHC in a health system lens (Figure 1).

Study design

This study adopted a descriptive qualitative study design to gather and analyze data from the iPHC conference abstracts and proceedings. In addition, we reviewed scholarly articles from Tanzania that are related to primary health care systems published from January 2013 to December 2023. Although our starting point was to review the iPHC materials, the addition of a literature review of scholarly materials provided additional evidence on which recommendations have been provided for the past 10 years in relation to each of the health system building blocks. Adopting a qualitative design helped us to examine and interpret data to uncover the recommendations for health system strengthening, but also gain an in-depth understanding of key issues related to each health system building block and beyond. In this study, we were guided by the World Health Organization (WHO) health system building block framework, but we also embraced recommendations that are beyond the building block framework to obtain a comprehensive and holistic picture of issues that are pertinent for building a resilient and responsive health system.

Data sources, tools and procedures

Data sources

To identify relevant data for this study, we followed the following steps; 1) Screening published abstracts for the iPHC from the Pan African Medical journal, accessible at [15], and also requested additional materials (conference proceedings, abstract book, and data) from the iPHC secretariat and accessed other information in iPHC website [16]. 2) Screening both peer-reviewed and grey literature related to primary health care in Tanzania published in English between 2013 and 2023. Guided by the WHO health system building blocks and beyond, we used search terms that are sufficient to describe the recommendations from the literature on strengthening health systems in Tanzania. We restricted the search to Tanzania and applied the Boolean search approach, using 'OR', 'AND', and nesting a plus symbol for the relationship between the concepts. The search terms are shown in Table 1. A total of 131 papers from the iPHC conference, scholarly articles, and reports were reviewed. The inclusion criteria for the papers in the review process were as follows; relevancy to Tanzania´s health system, especially PHC, addressed issues related to health systems strengthening, covered at least one of the health system building blocks, provide lesson learnt and recommendations relevant to the Tanzanian context, and published within 10 years from January 2013 to December 2023. Forty-eight (48) papers that met the inclusion criteria were included in the review, and 83 papers were excluded. The summary of the review process is shown in Figure 2 below.

Data extraction

To extract data for step 1, we used an extraction checklist (Annex 1). The extraction checklist included the following 1) Authors, 2) Title, 3) study objectives 4) Study design 5) Recommendations. For step 2, we used an extraction form organized in Excel and included the following information: date form completed; identification (ID) of the person extracting; year of publication, name(s) of author(s); study title; study design, publication type; health system block, recommendations (Annex 1).

Data collection procedures

Data extraction was done by VOL, MKJ, and NG. In case of any disagreements, a discussion was conducted between the three data extractors before referral to all authors if more information was needed.

Data analysis

Based on the extracted content, we performed analysis using a thematic analysis approach [17]. To analyze data the following steps were followed:1) to familiarize with the data, the authors read and re-read the extracted information and conducted discussions; 2) We generated initial codes deductively based on the health system building blocks and inductively by generating additional codes based on issues emerging from the data specifically, recommendations that are beyond the health system building blocks; 3) Themes were searched for each of the building blocks and beyond and thereafter, identified themes were presented in a tabular form for easy understanding and discussion by the authors; 4) The developed themes were reviewed by the authors (through a discussion) and areas of agreement and disagreement were identified and resolved through a consensus; 5) After consensus, the themes were developed for each building block and beyond; and 6) The defined themes were finalized and recorded to guide writing up the results of the current study.

Ethical considerations

The ethical approval was not required for this study since it was not a study on human subjects but rather a documentation of lessons learned to inform PHC strengthening efforts during iPHC conference. All the authors were members of the conference organization committee and hence had access and permission to use the conference data and materials from the conference chairperson.

Results     

Background information of the papers from the literature and the conference

A total of 131 papers from the iPHC conference, scholarly articles, and reports were reviewed. Forty-eight (48) papers met the inclusion criteria and were included in the review.

Unfinished agenda in health system across WHO building blocks

Informed by the reviewed literature and the conference papers, unfinished agenda items in the Tanzania health system across the WHO building blocks were identified and developed into themes. The developed themes are summarized in Table 2 and detailed in subsequent sections.

Health system recommendations across the WHO health system building block and beyond

Leadership and governance

Need for leadership and management training in PHC

Training of leaders and managers in primary health care is important to increase competency among health care managers for sustained health system stability and functioning. Training of leaders and managers in primary health care can be implemented through formal sessions on leadership, continuous professional development, and on job trainings [18]. The need for training is inevitable due to increased and fluctuating demands of the populations, advancement in technology, changes in community expectations, the emergence and re-emergence of diseases, the impact of climatic changes, and other contextual influences [19]. There are evidences that leadership and management training have positively impacted the health system outcomes in primary health care settings through accelerating the execution of health interventions [20]. Also, training of health managers improves leadership skills, which manifests in improved communication, collaboration, trust in care, innovations, thinking capacity, and fosters further learning and knowledge exchange [21]. For instance, in Tanzania, it was reported that leadership and management training among primary health managers was perceived as relevant and useful to them for implication of their routine activities [18].

Leadership as driver to achieve UHC

Strong and visionary leaders are crucial to achieving UHC. Establishing a strong, competent, and visionary health manager for the primary health care system could bring robust changes on the road towards UHC, since the primary health care system is the first point of contact to the modern medical system for the majority of Tanzanians. Incompetent leadership and governance of health systems affect the propagation of UHC practices and decisions [22]. Despite some efforts that have been observed over time in leadership and managerial aspects of health systems in Tanzania, still has not yet reached the anticipated outcomes of UHC, which calls for the need for system adjustments in managerial and leadership in PHC. Thus, the visionary and individuals with advanced knowledge on leadership should be encouraged by the system to bring changes [23]. Therefore, to achieve UHC in Tanzania visionary leaders are the key driver towards achieving the universal health coverage by 2030 through: developing resilient medical teams, strengthening communication, initiators and coordinators of health innovations in various aspects (data and making informed decisions) and implementing strategic and operational plans which will significantly impact on the achievement of universal health coverage in Tanzania [24].

Health workforce

Role of community health workers on optimization of health outcome

Community health workers form a link between the primary health care settings (communities) and the health system. Use of community health workers plays a key role on execution of health services from prevention, curative, to rehabilitative care through implementing individualized care, basically on equity and equality. Addressing health issues in the community by using the CHW can be of great importance in ensuring a healthy community, increased productivity, and stability of the health system generally. Community health workers play an important role in optimizing health outcomes, particularly in rural and hard-to-reach areas, where PHCs mostly operate and increase trust in government health services and accessibility of care [25,26]. A study from North East Tanzania showed that the use of community health workers resulted in increased ART adherence and high viral load suppression among HIV clients [27].

Need for human workforce professional development

Human resources for health form the cornerstone of health care delivery. They provide health care services to clients. Due to contextual fluctuations, climatic changes, merging and re-emerging of diseases, drug resistance issues, etc., there is a need for continuous professional development to meet the demands of clients effectively and efficiently. Inadequate training of health care workers leads to skills incompetence, which affects the quality of care in primary health care. Thus, to optimize efficiency and effective health care services, it requires continuous professional development [28]. The WHO recommended technical and professional training for tangible health outcomes [29]. Reports from Zanzibar, showed that training of health care workers (nurses and mid-wives) using skill labs contributed to increased competency in Post Abortion Care (CPAC), implants and Intrauterine Contraceptive Devices (IUCD) insertion and increased number of customers (patients) seeking for the services from 257 in 2020 to 928 in 2023 [30].

Address the shortage of health workforce in PHC

Health workforce shortage in primary health care has been a major challenge, which impairs the quality of health services. There is a need for the Government of Tanzania and stakeholders to come up with proper alternatives for addressing this challenge since it has been a longtime complaint. Tanzania has been experiencing a health workforce shortage, which is more severe in lower levels (primary health care setting) [31]. Different reports from Tanzania indicated a shortage of human resources in oral services and palliative care, which impaired the quality of service delivery to clients [32,33].

Health commodities

Health commodities are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage, with assured quality, and at a price that individuals and the community can afford [34].

The need to address the challenges for stockout of essential health commodities for quality health service delivery

The availability of essential health commodities in health facilities in Tanzania remains low [35,36]. Despite major improvements in the supply chain over the last several decades, essential health commodities availability has remained inconsistent [37]. A survey conducted in 54 public hospitals across the mainland of the United Republic of Tanzania found that 94% of hospitals were out of stock of one or more essential medical supplies, while 96% were out of stock of one or more essential medicines [36]. The study conducted in Lushoto District found that, 42% of patients did not get all prescribed medicines and medical supplies [38] Another study conducted in Arusha Region found that, 43% of the clients reported receiving all the prescribed medicines [39]. However, some improvement in the availability of essential health commodities is reported in some areas, for instance, the study conducted in four councils of Arusha region reported an average availability of essential health commodities by 91% [40].

Availability of essential health commodities varies according to the health care delivery level. The most important factors for variation reported by several studies were inadequate financing and operational inefficiencies [41]. According to [40] factors affecting commodities availability at National level were: increased demand, delayed shipments from donors, decreased funding commitments, delayed disbursement of funds, global shortages, inadequate governance, debt within the Medical Stores Department, donor dependency for vertical programme commodities and long lead times by medical stores department´s suppliers. At the regional and district levels, factors reported were a shortage of human resources, a lack of electronic medical records, limited interoperability of information systems, poor quality of logistics data, inadequate use of data for decision-making, and poor inventory management. At the healthcare facility level, an overwhelming number of exempted clients, which reduces facility revenues, was reported to affect essential health commodities prescribed to clients [40].

Integration of digitalized system in essential health commodities management to effectively support healthcare delivery

The healthcare supply chain performance and best practices can be improved by implementing digitalization initiatives. Digitalization of stock management at health facilities, like improved visibility of essential health commodities across all levels of health care delivery, is widely recognized. However, most of Tanzanian health care facilities lack adequate infrastructure to support digitalization [41]. The government is making strides in digitalizing Health Information Systems (HIS), but significant investments are needed to enhance the supply chain management of health commodities for quality health care delivery [42]. For instance, investment in digitalized system could help to clear the issue of poor inventory management which lead the patient to miss some of the prescribed medicine and medical supplies that were in stock as evidenced by the study conducted in Lushoto District which reported that, some of the undispensed medicines and medical supplies were in stock [38]. Also, it was reported that in Lushoto District lack of interoperability of information systems was among the reasons affecting the availability of essential health commodities [40].

Health information system &ICT

The use of integrated health information system and research data in planning serves as the basis for building a successful healthcare delivery system

A health information system provides the basis for the generation of high-quality data, and is a major component of the health system which serves as the foundation for building a successful national healthcare delivery system [43]. It incorporates the collection, processing, reporting, and use of information needed to improve the efficacy and efficiency of health services by enhancing management at all levels of the health system [43]. Without an integrated HIS, health information production and availability will be fragmented and sub-optimal [8]. According to the HIS guideline in Tanzania, a robust health information system is required for successful management of health care services, government accountability, transparency, and governance, as well as evaluating the impact of health policies in the country [42]. It is evident that, the use of integrated automated grants management system, which involved funders, facility management, and stakeholders, helped to coordinate information in the flow of funds and resulted to increased disbursement of funds from funding partners, which led to success in health care delivery among African countries Tanzania included [44].

The need for timely health information is driven by emerging health threats, performance-based funder disbursements [34] and results-based monitoring by government departments and development partners [42]. An intricate health information system can hinder accurate patient data transfer, hinder healthcare practitioners' access, and ultimately reduce the quality of healthcare delivery. Using a user-friendly data analysis and interpretation tool enabled regional and district TB coordinators to extract, analyse, and interpret TB surveillance data from the DHIS2 ETL independently. This led to improvements in reporting timeliness, data quality, and the ability to identify and explain major trends in TB and leprosy key indicators [45]. The quality of information provided in Electronic Medical Records (EMRs) at Chamwino District was one of the factors that resulted in the limited utilisation of EMRs data for decision making among health managers in primary health care [46]. A qualitative study conducted in Tanzania found that it is not common for health managers to utilize health research evidence for planning purpose [47]. The HIS is expected to quantify the quantity of disease morbidity and mortality in populations, track trends over time, detect and respond to any anomalous trends [34]. If health managers have limited capacity to use this information for planning, health care delivery in the country will be compromised. Therefore, Tanzania's disease control efforts require a strong health information system to enable decision-making at all levels, as spending grows. In order to promote information utilization and evidence- based decision-making, the Global Summit on Measurement and Accountability for Health urges all countries to implement health information flows, utilizing local data to enhance disease program effectiveness [48]. During the plenary forum in the first international primary health care conference, it was recommended that, Patient registers and data be digitalized to avoid duplications of investigations to the same patients at every level of the health facility and avoid double work for the health workers.

Addressing barriers of data use for evidence-based planning in primary health care

A qualitative study on data utilisation and factors influencing the performance of the health management information system in Tanzania found that one main challenge affecting health information use was insufficient human capacity in HIS to effectively apply analytical tools and methodologies for decision-making [49]. Similarly, the study conducted in Chamwino District found that, information quality, computer knowledge, computer access, and EMRs discussions during health managers' meetings all had an impact on data utilisation for decision-making [46] The study by [47] indicated that limited use of research findings in planning among health managers was influenced by a lack of motivation to use evidence, such as rewards, extra duty allowances, job promotion, and professional development.

Health financing

Health insurance education

The aspect of health financing forms the core functionality of the health system. For sustainable health financing in a limited resource areas, multiple approaches are required to finance the health system. Apart from the Government budget allocation and donor funds, health services beneficiaries should play a key role in financing the health system as well through out-of-pocket payments and or health insurance schemes. Since Tanzania has committed to attaining UHC through introducing health insurance for all, however, negative perceptions on health insurance can impair enrollment in the health insurance scheme [50]. Educating the communities about health insurance could be of great advantage in optimizing the enrollments to the scheme [51,52]. For instance, in North Western Tanzania, it was found that willingness to enroll in health insurance was attributed to education on health insurance provided [53].

Effective resource mobilization for improved health financing

Proper utilization and harmonization of both external and domestic finances (planning, reporting) plays a significant role in the expansion of primary health care services and increases facility finances; however, it requires addressing the political & structural barriers and proper financial planning [37]. Example, proper planning and mobilization of resources in 15 councils on an increase in the budget allocated for NTD interventions from domestic sources. Also, the study findings showed that more NTD data were incorporated into the health management information system (HMIS) [54].

Health services delivery

Invest on comprehensive care services delivery

There has been a notable expansion of comprehensive care services in primary health care services in Tanzania including oral care, eye care, fistula care, and palliative care [32,55,56]. However, to strength health services and minimize unnecessary referral pressures to high-level facilities, foster early detection of health problems, there is a need for massive investment in comprehensive care in primary health facilities.

Marketing of the primary health services

Proper marketing strategies are important in attaining maximum awareness and uptake of services in primary health care [57,58]. To this end, investing in comprehensive care alone is not enough without marketing strategies. Marketing can be fostered by the use of a client charter, which provides clients with awareness and information of the services provided by the health facility in the context of service delivery [57].

Improve health service quality

Along with increasing accessibility of health care services in UHC, the WHO emphasized the assurance that the services are of good quality, meaning effective, safe, and client-centered [59]. Report from Arusha revealed that 230 (85%) of the clients had a positive experience with care processes, 181 (72%) clients were satisfied with the health services, and most of the clients (n= 230.85%) had confidence and trust in public primary health services [39]. However, in Tanga it was revealed that long waiting times, failure to take vital signs, inadequate physical examination, low client access all medicines, and inadequate treatment explanations to clients were the potential causes of clients´ complains to quality of service delivery [30].

Beyond the building block

Political will as driver to PHC

A strong political will emerged as an essential drive of the current witnessed achievements in PHC in Tanzania. In a Pannel discussion, one member of the forum echoed “To achieve strong and sustainable resilient primary health care in Tanzania (strengthen infrastructure, establishment of comprehensive care, addressing HRH, financing etc.) still demands a strong political will because it is a cross-cutting domain”. Integration of political domains in health care could lead to great achievements [60].

Funders policies

Investing funds in single domains (disease-specific areas) poses a challenge that impairs the efficiency of primary health care in Tanzania. In a forum on discussion for sustainable financing, it was recommended that for resilient financing in primary health care services, there is a need for integration and collaboration in financing policies and guidelines to minimize fragmentation. Tanzania has started the implementation of integrating vertical programs to horizontal services, intending to increase health service coverage (full package services) and will still advance the integration to accommodate wide service areas for effective and responsible health system functioning with a strong focus on PHC (Elaborated by one Senior Government of Tanzania (GoT) Official).

Strengthening community health system

Empowering the community health system through community participation and decision-making fosters ownership and sustainability of health programs, i.e., addressing PHC from its roots. Investing in the community has a great contribution to the propagation of health services, cooperation, and is a key driver towards UHC [61,62]. The MOH, PORALG, with partner´s organization is currently fuelling the agenda of an integrated and coordinated community health worker program, which entails capacitating the CHW with multiple health competencies rather than disease-specific management. The program is deemed to have a massive success in enhancing health system performance.

Develop strategies to mitigate the effects of climate change in PHC

Tanzania is facing severe weather extremes due to climate change, causing increased temperatures, droughts, and erratic rainfall, affecting public health and livelihoods due to emerging health threats related to wet and dry El-nino, with projections predicting intensification [63]. If Tanzania's capacity for climate resilience is not addressed, it would certainly have a dramatic impact on slowing universal health coverage. Robust strategies to address climate and health threats within PHC settings is of paramount importance. During the plenary discussion in the first internal primary health conference (2024), it was recommended that multisectoral efforts are still needed for better health emergency prevention, preparedness, response, and resilience.

Discussion     

The overall aim of this paper was to explore health system strengthening recommendations from the 1st iPHC conference in Tanzania to guide efforts to strengthen PHC system. The main findings included the need for continuous professional development to enhance technical skills, availing adequate skills mix human resources, leadership and managerial skills, promote data use to support decision-making in planning and service delivery, community education to improve health insurance coverage, improve the quality and expansion of the package of services offered in PHC, digitalization and system integration, ensuring consistent availability of health commodities, strengthen community health system and addressing issues beyond the health system including climate change. Achieving UHC requires distribution of resources to match the required needs [64]. The findings for the need to address the shortage of skills mix human resources for health are consistent with other findings in the literature [65-67]. Strengthening human resources for health function should go hand in hand with the need for continuous professional training to enhance the technical skills, which is critical to match with advancement in technology and technical know-how in managing patients [68].

Strong and committed leadership is important to ensure resources are managed effectively in order to achieve intended goals. Leaders and managers in health care should possess the ability to foresee the challenges, identify problems, establish solutions to address the problems, and properly plan for the solution [66,69]. Thus, poor leadership forms the barrier towards achieving the UHC [70]. Training leaders and managers in PHC could strengthen leadership competencies [18,71]. The same was reported by Kingu et al. [72] that training is the key aspect for strengthening leadership and managerial competencies. Ensuring consistent availability of health commodities plays a significant role in enriching client´s expectations and satisfaction while encountering the health system [73,74]. Effective demand planning and quantification is crucial to ensure consistent availability of health commodities [40,74].

Sustainable health financing mechanism through tapping the potential of domestic financial resources and institutionalization of a functional system for data used to inform operational and strategic decisions in the provision of health services [5,11,75-80]. In order to maximize the potential of health insurance schemes as among important source of domestic health financing mechanism; community education to enhance the understanding of the scheme and awareness is critical for success as reported in our findings, similar to other recommendations in the literature [75,77].

Digitalization plays a major role in improving data use and service delivery. Globally, there is a major transformation of the health systems and provision of health care services through the use of Information and Communication Technologies (ICT) [78-80]. Accessing quality data is important for planning, monitoring and evaluation of the provision of services and decision-making. Digitalization is among the central support structures to ensure real-time data. Nevertheless, the setbacks in fragmentation of digital systems needs to be addressed through enhancing interoperability and integration of digital systems as reported in our study similar to other findings in Tanzania [11,40,81].

Needless to say, in reaching the goals of the UHC, the importance of embarking on the provision of quality services for already available services and the expansion of the scope to include other interventions within the package, such as oral health and palliative care, need to be advocated to achieve adequate and effective coverage. This finding is also reported elsewhere in the literature [75,82]. For efficiency and effectiveness, integrations of services at PHC need to be advocated [83,84].

Strengthening the PHC system in Tanzania is essential for improving the coverage, health care quality, and financial risk protection [4]. Our findings suggest that efforts towards making Tanzania health system responsive and resilient require a multifaceted approach. We propose a four-fold pathway towards success. First, it is important to focus on building the human resource for health capacity, both qualitative and quantitative, to champion the implementation and also to spearhead the vision towards making the health system responsive and resilient [64,66]. Innovation through task shifting and task sharing could address some gaps related to the availability of health care workers [85]. Moreover, the strategy of utilization of Community health workers needs to be emphasized to strengthen health prevention and preventive services [86]. Additionally, the role of training institutions for cost-efficient training and sharing of expertise needs to be emphasized, coupled with a mentorship program to enhance professional development skills in managerial and technical tasks. Revitalization and strengthening of institutions such as Primary Health Care Institute, Iringa (PHCI), and Centre for Education Development in Health Arusha (CEDHA) established to coordinate and champion continuous professional training, need to be prioritized [87].

Second, ensuring the availability of required promotive, preventive, curative, palliative, and rehabilitative services through increasing geographical access and availing necessary resources is essential for the initial utilization of services, continuous utilization, adequate and effective coverage [88]. Targeting investment in the PHC provides a quick win to improve the coverage of health services [8,9,89]. Third, effort in mobilization of domestic resources to finance the health sector and for sustainability purposes needs to be reinforced. Evidence from Tanzania National Health Accounts 2022 shows that the share of domestic financing of Tanzania health expenditure increased from 59% to 66% with non-government domestic resources, mostly from households rather than insurance schemes (high out of pocket expenditure) that poses a risk towards catastrophic health expenditure [90]. Advocacy and education to the community are mandatory to increase the pool of the pre-payment health insurance scheme. Additionally, the Government of Tanzania needs to allocate more funding to the PHC and empower health care managers with skills and knowledge in identifying funding opportunities and preparing grant proposals to increase funding to the PHC whereas the current funding envelope in most low- and middle-income countries is below the threshold set by WHO in achieving UHC [91].

Fourth, strategies for addressing issues beyond health system building blocks, in particular emerging global health threats such as climate changes, is critical. Awareness creation towards investment in eco-friendly technology, building systems for early warning and response in addressing the effect of climate change related to dray and wet El-Nino [92] should be part and parcel of investment strategies in strengthening the PHC system. Finally, for success, political commitments and intersectoral coordination play a critical role in building a responsive and resilient health system [7,93].

Strengths and limitations: this study has a number of strengths. It reflects a comprehensive picture of the view of health system stakeholders from different backgrounds and nations that participated in the conference. Moreover, the information tapped from other literature for triangulation ensure validity of the findings. Despite the strengths, this study had some limitation worth acknowledging 1) We did not conduct a quality check of the included materials (abstracts, conference summaries, and scholarly literature) 2) Most of the study were observational in nature, and therefore, the recommendations extracted could be prone to the limitations of observational evidence.

Conclusion     

Health system strengthening efforts in Tanzania, towards UHC, require a multifaceted approach. Strategies geared towards the improvement of supply-side bottlenecks, coupled with intervention in the demand side, are required. Moreover, the role of political commitments and intersectoral collaboration for tackling issues beyond the health system and emerging global health challenges, such as emerging and re-emerging diseases and climate change, is critical.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

James Tumaini Kengia conceptualized and designed the study and drafted the manuscript. Albino Kalolo, Victoria Odemary Lyimo, Nyasiro Sophia Gibore, Mwandu Kini Jiyenze, Amani Kikula conducted the literature review, data analysis, drafted the manuscript, Anosisye Kesale, Louis Nicas, Leonard Katalambula, Pius Kagoma, Jackline Eugene Ngowi, Dastan Mshana, Mageda Kihulya, Grace Magembe, Kasusu Klint Nyamuryekung´e, Paulo Chaote, Rashid Said Mfaume, Ntuli Angyelile Kapologwe, Bruno Sunguya, Wilson Mahera Charles substantively revised the manuscript. All the authors have read and agreed to the final manuscript.

Acknowledgments     

We would like to express our sincere thanks to all delegates of iPHC conference, their participation in the conference, made it possible to have this publication.

Tables     

Table 1: list of search terms used in the study

Table 2: distribution of themes per WHO health system building blocks and beyond

Figure 1: distribution of conference participants by nationality

Figure 1: the flow chart of the paper selection and review process

Annex     

Annex 1: supplementary materials (PDF 286KB)

References