Factors influencing drug revolving fund guideline implementation among public primary health facilities in Magu and Kwimba districts, Tanzania: a qualitative exploratory study

¹Department of Behavioral Sciences, School of Public Health and Social Sciences, Muhimbili, Dar es saalam, Tanzania, ²Department of Health, Social Welfare and Nutrition Services, Kwimba District Council, Mwanza, Tanzania,³Department of Health Research, Social welfare and nutrition services, Nanyumbu District, Mtwara, Tanzania

^&Corresponding author
Fransiscko Fundi, Department of Health Research, Social welfare and nutrition services, Nanyumbu District, Mtwara, Tanzania

Introduction    

To achieve Universal Health Coverage (UHC), the World Health Organization advised shifting health systems toward primary health care (PHC) [1]. This necessitated the provision of essential medicines and medical supplies as fundamental components of PHC [2]. Consequently, many developing countries adopted free health services funded through national budgets [3]. However, low- and middle-income countries faced economic constraints limiting full implementation, leading to recurrent shortages of essential medicines [4,5]. A World Health Organization survey in the mid-1980s revealed that approximately 60% of Sub-Saharan African countries lacked regular access to essential drugs, prompting African health ministers to convene in Bamako, Mali, in 1987 [6,7]. The resulting Bamako Initiative aimed to ensure universal access to quality basic health care through community participation and user contributions via revolving drug funds [2]. The DRF scheme is a community financing mechanism for essential drugs at full cost recovery, mobilizing financial resources based on community willingness to pay [3,8]. Theoretically, drug supplies continue indefinitely without further government budget allocations as long as sales revenues suffice to purchase new drugs [9]. Several pilots across sub-Saharan Africa demonstrated significant improvements in drug availability in facilities implementing the Bamako Initiative effectively, with mean essential drug availability increasing to 90-95% [10-13].

In Tanzania, the DRF scheme was formally established in 1998 to improve localized drug replenishment pathways, mitigate persistent drug shortages, and optimize revenue utilization within decentralized health structures [14,15]. To adapt to evolving health system decentralization and digital financial management systems, the Tanzanian Ministry of Health issued the updated Health Commodities Revolving Fund Guideline in 2020 [14] With the release of this policy framework, it was anticipated that all public primary health facilities and district health management teams would strictly adhere to its standardized financial and administrative protocols to ensure fund capital preservation and continuous drug availability [14]. Under this national guideline, adherence is explicitly defined across four primary operational domains: financial segregation, revenue allocation, standardized pricing structures, and routine monitoring and reporting. First, financial segregation mandates that every public primary health facility maintain a dedicated, ring-fenced bank account exclusively reserved for health commodity transactions to prevent the diversion of drug revenues into general facility operations [14,15]. Second, the revenue allocation domain dictates that facilities must directly reinvest 100% of internal revenues generated from essential drug sales back into commodity replenishment, supplemented by designated revenue-sharing percentages collected from user fees, the National Health Insurance Fund (NHIF), and the improved Community Health Fund (iCHF) [14,15].

Third, the pricing structure provision enforces a mandatory 30% profit markup on non-exempt essential commodities sold at health facility pharmacies to absorb operational losses, buffer against inflation, and generate net revolving capital [14,15]. Finally, the monitoring and reporting domain requires accurate, real-time documentation of all commodity sales, stock movements, and user-fee exemptions within the digital Government of Tanzania Hospital Financial Management Information System (GoT-HOMIS), alongside the regular submission of standalone DRF financial reports to district supervisors [14,15]. Despite the comprehensive design and formal dissemination of the 2020 guideline, primary health facilities across Tanzania continue to experience severe, chronic stock-outs of essential medicines due to rapid fund decapitalization and widespread guideline non-compliance [4,9,16,17]. While broad health system literature frequently cites weak financial controls and logistical bottlenecks as general implementation hurdles, limited empirical research exists that systematically explores the specific structural, administrative, and behavioral factors hindering guideline adherence at the facility and district levels [9,18]. Furthermore, frontline health facility managers operate at the complex intersection of clinical service delivery, district administrative oversight, and national public finance management policies, creating potential operational frictions that remain under-investigated [9].

To systematically explore why health facilities, adhere or fail to adhere to national DRF provisions, this study was grounded in the Consolidated Framework for Implementation Research (CFIR) [19]. The CFIR framework offers a comprehensive, multi-dimensional analytical lens to evaluate implementation outcomes across five core construct domains: intervention characteristics (such as the perceived complexity, clarity, and adaptability of the 2020 DRF guideline), outer setting (including national treasury directives, PO-RALG public finance regulations, and uncompensated national exemption policies), inner setting (encompassing facility-level accounting infrastructure, administrative leadership, and resource availability), characteristics of Individuals (such as healthcare worker policy knowledge, familiarity, and self-efficacy), and implementation process (including supervisory tracking, auditing routines, and administrative drive). By applying this framework, guideline adherence was comprehensively evaluated across both individual implementer practices and structural, facility- and district-level operations. Therefore, this study aimed to explore the multidimensional factors influencing adherence to the 2020 drug revolving fund guidelines during scheme execution in public primary health facilities within the Magu and Kwimba districts of Tanzania.

Methods     

Study design and setting: a cross-sectional exploratory qualitative study design was employed to assess factors influencing adherence to the drug revolving fund (DRF) guidelines during implementation of the DRF scheme in public primary health facilities in Kwimba and Magu Districts, Tanzania. These councils were purposefully selected because they had the lowest and highest proportions of essential medicine stock-outs, respectively. The study was conducted in June 2023 across four public primary health facilities and two district council health management teams. To distinguish policy awareness from actual implementation compliance, operational adherence was assessed across both individual implementer practices and facility/district operations by systematically exploring participants' reported experiences in implementing the four mandatory operational domains outlined in the 2020 DRF guideline: financial segregation (operating a ring-fenced commodity bank account), revenue allocation (100% reinvestment of drug revenue alongside specified user-fee/insurance shares), pricing structure (applying a mandatory 30% profit markup on non-exempt items), and monitoring and reporting (tracking via GoT-HOMIS and submitting standalone quarterly DRF reports) [14].

Population and study criteria: the study population comprised members of council health management teams (CHMT) and facility health management teams (FHMT) from Kwimba and Magu Districts who were directly involved in DRF scheme implementation, supportive supervision, mentoring, and guideline dissemination. Inclusion criteria mandated that participants were members of CHMTs or FHMTs working in the selected districts; held direct administrative, signature, or accounting authority over DRF scheme execution or financial oversight, and provided voluntary written informed consent to participate. Exclusion criteria applied to health workers not directly involved in DRF implementation or financial management and those who declined to participate.

Sample size and sampling procedures: purposive sampling was used to recruit 12 key informants possessing direct operational knowledge of DRF scheme implementation and commodity financing. At the district level, CHMT members directly involved in supportive supervision, mentoring, and guideline dissemination, including District Health Secretaries, District pharmacists, and CHMT coordinators, were selected to evaluate system oversight. At the facility level, FHMT key implementers, including medical officers in-charge, assistant medical officers, and facility pharmacists/technologists, were selected. Equal geographical and administrative representation was maintained, with 6 participants recruited from Magu District and 6 from Kwimba District (N=12). Sample size determination was guided by the principle of data saturation [20]. Data collection and preliminary coding proceeded iteratively after every interview. Information saturation was operationalized as the point at which no new primary codes, sub-themes, or systemic financial conflicts emerged from subsequent transcripts. Data saturation was formally achieved at 12 interviews, as the final two interviews across both districts yielded no additional operational perspectives regarding financial barriers or guideline execution, confirming sample size sufficiency [20,21].

Data collection: two semi-structured interview guides were developed by the primary researcher with supervisory assistance and pre-tested in a non-study district. One guide targeted CHMT members (policy dissemination, supervision, treasury integration), and the second targeted FHMT members (revenue collection, procurement, exemption tracking, accounting). Data were collected in June 2023 through face-to-face interviews. Appointments were scheduled via visits and phone calls. The primary researcher (MJ), an MPH candidate trained in qualitative methods, conducted all interviews. Each interview lasted approximately 45 minutes, was conducted in Kiswahili, audio-recorded with written permission, and transcribed verbatim with translation into English. Field notes captured contextual nuances. To triangulate participant perceptions and verify policy contradictions, key national policy documents were reviewed, including the 2020 health commodities revolving fund guideline, the public finance act, and Tamisemi financial guidelines on treasury single account (TSA) and facility financial accounting and reporting system (FFARS) operations. To minimize social desirability and institutional-response bias, the interviewer established an academic, non-evaluative stance, clarified the study was not a government audit, assured anonymity, conducted interviews in private settings, and used open-ended, non-judgmental probing questions.

Data analysis: data were analyzed thematically with coding aided by NVivo version 12, employing a hybrid deductive-inductive thematic approach [22]. Audio recordings were transcribed verbatim in Kiswahili and translated into English. Deductive codes were structured around the Consolidated Framework for Implementation Research (CFIR) construct domains [19] and 2020 DRF guideline provisions [2,14], while inductive codes captured emergent themes from interview narratives. Data analysis followed three iterative coding stages: open coding to identify meaningful text segments, axial coding to aggregate codes into sub-themes, and selective coding to establish overarching themes aligned with study objectives. To ensure inter-coder reliability and methodological rigor, two researchers (MJ and DN) independently coded all transcripts using the same codebook. To ensure inter-coder reliability and methodological rigor, two researchers (MJ and DN) independently coded all transcripts using the same codebook. Coding discrepancies were systematically documented and resolved through consensus discussions; when agreement could not be reached, a third senior researcher (TR) was consulted to arbitrate. This iterative consensus process ensured that final themes accurately reflected the range of participant perspectives. Final themes were validated through data triangulation across interview transcripts, field notes, and document reviews, and were supported using verbatim anonymized participant quotations (e.g., CHMT-01, FHMT-03). Member checking, audit trails, and verbatim transcription further enhanced credibility and trustworthiness.

Ethical consideration: ethical clearance was obtained from Muhimbili University of Health and Allied Sciences (MUHAS) Institutional Review Board (Reference: DA.282/298/01.C/1727, dated 12/06/2023). Permission to conduct the study was obtained from the Magu and Kwimba District Executive Directors. Following extensive explanations of the study objectives and procedures, all participants provided written informed consent. Participants were assured that all information they provided would remain confidential and would be used solely for research purposes. Interviews were conducted in private settings to ensure confidentiality. Participants were informed of their right to withdraw from the study at any time without consequences.

Results     

A total of 12 key informants participated in the study (6 from Magu District, 6 from Kwimba District). Respondents' ages ranged from 34 to 52 years. Table 1 presents the demographic and professional profile of each participant. All participant identifiers were standardized using codes to protect anonymity: Council Health Management Team (CHMT) members were coded as CHMT-01 through CHMT-06, and Facility Health Management Team (FHMT) members were coded as FHMT-01 through FHMT-06. Four main themes emerged: i) awareness of DRF guideline content, ii) financial procedures affecting DRF implementation, iii) monitoring systems for the DRF, and iv) operational factors influencing adherence. Each theme comprised several sub-themes as presented below.

Theme 1: awareness of DRF guideline content: this theme captured participants' knowledge of the DRF guideline's existence, financial requirements, and monitoring provisions. Awareness was critically low across all levels, from facility workers to council management teams. A key finding was the critical distinction between policy awareness deficits and procedural non-adherence driven by structural constraints. Even facilities where managers were familiar with DRF guidelines failed to adhere due to conflicting national financial regulations. Three sub-themes emerged: awareness of guideline existence, awareness of financial requirements, and awareness of monitoring requirements.

Awareness of guideline existence: despite the development and dissemination of the DRF guideline to all regions and districts, the study found that some respondents were completely unaware of its existence. During interviews, when participants were asked about their knowledge of any guiding document for DRF implementation, one participant responded: " I don't know if there is a guideline for a revolving drug fund; all I know is that the scheme uses acost-sharing guideline to allocate funds for the procurement of medications" (FHMT-04, Facility Health Secretary, Magu) While most participants reported awareness of the guideline's existence, the study revealed that the majority had never read or seen the document. When asked whether they had access to the guideline, one participant stated: "About the guideline for drug revolving fund, I only have heard about it but have never seen it" (FHMT-06, Assistant Medical Officer, Magu). Inadequate dissemination was identified as the primary reason for low awareness. During fieldwork, participants consistently mentioned that the guideline was not adequately distributed. One participant explained that the guideline was introduced to only a few CHMT members with no continuation to health facilities: " [...] the guideline was introduced to few CHMT members, and very few copies were distributed [...]" (CHMT-02, District Pharmacist, Magu). Furthermore, the study found that no training or supportive supervision had been conducted to empower health workers. When asked about capacity-building initiatives, one participant confirmed: " Currently there is no training that has been provided to facilities on implementation of the drug revolving fund scheme [...]" (CHMT-03, District Pharmacist, Kwimba).

Awareness of financial requirements: the interviewed participants were managers and planners responsible for facility allocations and budgeting. Despite this important role, the study found that some were unaware of the percentage shares from various collection sources required for the DRF. When asked about the required percentage contributions to the DRF account, one participant responded: " I am not sure about it, because what we do is to procure medicines in accordance with the already existing budget, so we usually press order to the prime vendor with respect to the amount of money present in the account for medicines" (FHMT-02, Medical Officer In-charge, Magu).

Awareness of monitoring requirements: monitoring of the DRF scheme starts with tracking dispensed medicines and medical supplies for appropriate replenishment. The guideline provides specific monitoring criteria, but the study found that healthcare workers were not aware of these requirements. When asked to explain the monitoring system components as described in the guideline, all participants could not correctly respond. One participant stated: " I don't know exactly about the drug revolving fund monitoring, but I know about monitoring of the drugs themselves by just experience, not from the guideline" (FHMT-03, Facility Pharmacist, Kwimba). Even CHMT members, expected to serve as mentors, trainers, and supervisors, lacked adequate awareness. During interviews, one participant expressed concern: " Even the CHMT members themselves are not adequately aware of the guideline and what and how to implement it, thus why there is no monitoring, supervision, and mentorship provided to lower facilities with regard to the drug revolving" (CHMT-06, District Medical Officer, Magu)

Theme 2: financial procedures affecting DRF implementation: this theme encompassed financial systems, policies, and procedural requirements that hindered guideline adherence. Participants reported contradictory policies between ministries, rigid budgeting systems that conflicted with DRF requirements, and procurement processes causing delays. Three sub-themes emerged: bank account operating process, budgetary process, and prime vendor system.

Bank account operating process: the DRF guideline requires a separate bank account, but the study found that bureaucratic processes and contradictory policies hinder this. This contradiction arises from a fundamental policy misalignment between the Ministry of Health's DRF guideline and the Ministry of Finance/PO-RALG directives. The DRF guideline mandates separate, ring-fenced bank accounts for healthcare commodities. However, the Treasury Single Account (TSA) system and the Facility Financial Accounting and Reporting System (FFARS), enforced by the President's Office Regional Administration and Local Government (PO-RALG/TAMISEMI), restrict public primary health facilities to maintaining a single unified government bank account. This contradiction exists at the national policy level. Document reviews of the Public Finance Act and TAMISEMI financial guidelines confirmed that no formal administrative waiver has been issued by the Ministry of Finance to permit secondary DRF accounts. This policy conflict was independently verified through document review, not based solely on participant perceptions. Participants noted that Ministry of Finance and TAMISEMI guidelines allow only one bank account per facility recognized by the central government. When asked about challenges in operating separate bank accounts, one participant explained: " [...] up to now, the guideline limits the facilities to operate one account per facility that is recognized by the national treasury. So, when it comes to the issue of opening a special bank account for the drug revolving fund, it is still not permitted. Leaders at the ministry level must harmonize this." (CHMT-01, District Health Secretary, Kwimba)

Budgetary process: the study found that participants reported that cost sharing and CCHP budgeting guidelines require 50% allocation for medicines, whereas the DRF guideline requires 100% of collections from drug sales for replenishment. During interviews, participants explained that budgets are fixed for the entire financial year, limiting flexibility. One participant elaborated: " [...] however, there are other budgetary guideline which limits during implementation of this guideline, if we look for example in the budgetary guideline CCHP guidelines which guides us to allocate 50% from internal sources such as user fee, NHIF and CHF, and 35% of HSBF for procurement of medicines and medical supplies, but also we cannot procure more than what is in the budget even if we have collected more" (CHMT-01, District Health Secretary, Kwimba).

Prime vendor system the study revealed that the single prime vendor system per region creates delays when items are out of stock, requiring special permits from the Regional Administrative Secretary. When asked about procurement challenges, one participant stated: " Also, the prime vendor system allows us to procure medicines if MSD is out of stock from one prime vendor only, if the prime vendor don't have such medicines gives us out of stock and we make a special request to the district director and regional administrative secretary to procure from other private pharmacies, this takes long and bureaucratic procedures might take 3-4 months, which is not healthy for the institution and the served community" (FHMT-01, Medical Officer In-charge, Kwimba)

Theme 3: monitoring systems for the DRF: this theme captured mechanisms, tools, and capacities for tracking DRF performance. Monitoring systems were virtually non-existent, with no formal tools for tracking fund growth, medicine replenishment, or scheme progress. This gap prevented early problem identification and evidence-based decision-making. Two sub-themes emerged: analytical skills and techniques, and monitoring tools.

Analytical skills and techniques: the study found that facilities lacked skills and technology to analyze revenue specifically for each charged item type. Participants reported that facilities lack a potential health management information system with competent analytical software packages. When asked about their ability to track specific collections, one participant explained: " [...] the new drug revolving fund is difficult to determine the specific collections from, for example, drugs, consultation, diagnostic investigations and procedural charges in most of the health facilities due to lack of efficient health information in the facilities; in this essence we fail to get data for determination of expected collections from specific charges" (CHMT-03, District Pharmacist, Kwimba).

Monitoring tools: the study found that no monitoring tools had been developed by CHMT or facilities. When asked about monitoring mechanisms, participants cited a lack of knowledge on monitoring requirements. One participant stated: " There is no tool developed by the CHMT for monitoring the implementation of the guideline, and so most of the health facilities do not follow the guideline; they purchase drugs in respect of their needs and available funds at the time" (CHMT-03, District Pharmacist, Kwimba). The study also revealed that tracking systems for dispensed medicines were absent. When asked how they ensure replenishment of dispensed medicines, one participant noted: " We don't have a tracking system to monitor drugs that are dispensed to make sure they are replenished, but we do purchase by looking at which medicines are needed" (FHMT-05, Pharmaceutical Technologist, Kwimba). When asked regarding reporting mechanisms, the study found that monthly, quarterly, and annual progress reports were not prepared. One participant explained: " There is no specific report that is reported to the district and higher authorities; we rather make a comprehensive report all together with other reports" (FHMT-01, Medical Officer In-charge, Kwimba)" . Another participant confirmed: " No, we don't have a revolving drug fund report; we only report medicine reports but not drug fund as report otherwise if you have requested to report a specific item" (CHMT-03, District Pharmacist, Kwimba).

Theme 4: operational factors influencing adherence: this theme captured practical, day-to-day challenges affecting implementation beyond policy issues. Exemptions represented a major financial drain, with 50-60% of medicines dispensed without adequate reimbursement. Administrative commitment was insufficient, with no follow-up or support from higher authorities. Two sub-themes emerged: exemption burden and administrative commitment.

Exemption burden: participants estimated that exemptions, defined as medicines provided free of charge to exempted patient groups under Tanzania's national exemption policy, accounted for approximately 50-60% of the total financial value of all commodities dispensed at primary health facilities. This estimate was based on monthly pharmacy dispensing registers cross-referenced with billing logs, typically calculated over a quarterly period. The burden is primarily driven by three statutory exemption categories: maternal health services (antenatal care, delivery commodities, and post-natal care), pediatric care for children under five years of age, and chronic illness management (including elderly care, tuberculosis, and HIV co-infections). The study found that exemption costs, particularly for obstetrics and children, were approximately 50-60% of total costs, exceeding reimbursement from the central government. When asked about challenges in maintaining the fund, one participant explained: " We wish to replace 100% of dispensed medicines, but 60% of our drugs go to pregnant women and children under five who do not pay a single shilling. The government capitation does not cover the cost of these dispensed drugs. The drug fund cannot revolve when capital is given away for free without reimbursement." (FHMT-03, Facility Pharmacist, Kwimba). Another participant added: " we wish that dispensed medicines are procured in full replacement, but the challenge is that most of the drugs are dispensed to exemption patients [...] a cost higher than reimbursement from central government; due to the needs of the hospital, you must think of additional from other sources in order to make sure you get adequate medicines" (CHMT-01, District Health Secretary, Kwimba).

Administrative commitment: the study revealed that participants reported insufficient administrative commitment to implement the guideline, with no follow-up from higher authorities. When asked about support from higher levels, one participant stated: " Third reason is lack of commitment at all levels on implementation of the drug revolving fund guideline, as you can see that since dissemination of the guideline there is no follow-up at the district level down to the facility, no report has been requested by the higher authorities regarding progress of the funds" (FHMT-01, Medical Officer In-charge, Kwimba). The study also found that health stakeholders have not prioritized DRF as a strategy to address drug shortages. One participant elaborated: " The fundamental challenge is that most of the health staff are unaware of the content of the guideline and how to follow it, and there are no trainings on this area, the ministry and other health stakeholders have not taken on the weight of the implementation of this guideline as a strategy to combat the issue of drug scarcity in primary health facilities, which have been a chronic illness" (CHMT-06, District Medical Officer, Magu).

Discussion     

This qualitative exploratory study evaluated the factors influencing adherence to the 2020 DRF guidelines in primary public health facilities in Magu and Kwimba districts. The study identified key barriers across outer policy settings (national treasury directives and exemption policies), inner accounting environments (facility-level infrastructure and leadership), and implementation processes (supervisory tracking and administrative drive). The findings reveal significant systemic barriers that participants perceived to collectively undermine effective DRF implementation and contribute to persistent essential medicine shortages. A major contribution of this study is the conceptual distinction between policy awareness and actual adherence. While low awareness of the 2020 DRF guideline was widespread due to inadequate dissemination and absent training, our findings demonstrate that improving knowledge alone will not guarantee compliance. Healthcare managers who were aware of DRF mandates were still unable to adhere to revenue-segregation rules because of high-level administrative constraints. This aligns with implementation science literature, which highlights that individual knowledge is a necessary but insufficient prerequisite for policy compliance when structural bottlenecks exist in the outer setting [23-25].

The situation was particularly concerning because even CHMT members expected to serve as overseers and mentors lacked adequate awareness. This creates a cascade effect: if supervisors do not understand the guideline, they cannot effectively train, monitor, or support facility-level implementers. The absence of formal training and supportive supervision further compounds this problem, leaving health workers to rely on other conflicting guidelines such as cost-sharing policies. This finding aligns with Ogunsola et al., who emphasized that effective dissemination, availability of guideline copies at all facilities, and regular supportive supervision are essential for improving awareness and implementation [23]. Financial procedures emerged as a major barrier to guideline adherence. The study identified a fundamental policy contradiction in Tanzania's public health management: the Ministry of Health's DRF guideline mandates a separate facility-level DRF bank account, whereas PO-RALG and Ministry of finance regulations restrict facilities to a single Treasury single account (TSA) managed through facility financial accounting and reporting system (FFARS) [26-28]. This contradiction has not been previously documented in the Tanzanian context and represents an important contribution of this study. Without separate accounts, DRF funds are pooled with other facility revenues, making them vulnerable to diversion for non-medicine activities.

The literature supports that successful DRF schemes require well-functioning financial management systems with separate bank accounts for effective income collection, allocation, and cost recovery analysis [9]. Evidence from successful DRF models in Sudan and Kenya demonstrates that maintaining ring-fenced commodity accounts is essential to prevent decapitalization and ensure full cost recovery [3,8,13]. Achieving adherence in Tanzania will require inter-ministerial harmonization between the Ministry of health, PO-RALG, and the Ministry of finance. Similarly, rigid budgetary processes constrained adherence to DRF requirements. While the DRF guideline mandates 100% replenishment of drug sales, Comprehensive council health plan (CCHP) budgeting guidelines require only 50% allocation for medicines, and budgets are fixed for entire financial years [14,29]. This inflexibility prevents facilities from responding to actual collection patterns and implementing percentage shares as stipulated in the DRF guideline. The single prime vendor system further exacerbates procurement challenges, causing delays of 3-4 months when items are out of stock, requiring special permits from the Regional Administrative Secretary. These findings are consistent with several studies documented similar procurement bottlenecks in Tanzanian health facilities [24,25,28].

The absence of monitoring systems for the DRF represents a critical gap. Participants reported no formal tools for tracking fund growth, medicine replenishment, or scheme progress. Facilities lacked the analytical skills and technology to analyze revenue specifically for each charged item type, making it impossible to determine whether the fund was growing or decapitalizing. A study in Kenya argue that DRF success depends on effective monitoring and evaluation by competent teams. Without such systems, problems cannot be identified early, and corrective actions cannot be taken [13]. This study contributes new evidence on the specific monitoring gaps in Tanzanian primary health facilities. Operational factors, particularly exemption burden, further constrained DRF implementation. In theory, DRFs function as self-sustaining capital loops [2,9]. However, when primary facilities dispense over half of their commodity stock to exempt populations (maternal, under-five, and chronic illness patients) without prompt, full-value reimbursement from national funding streams, the revolving mechanism breaks down [9,17]. Similar studies in Nigeria and Ghana revealed that uncompensated user-fee exemptions represent the single largest contributor to DRF decapitalization in primary healthcare settings [9,18]. Administrative commitment emerged as a cross-cutting factor influencing all other themes. Participants reported insufficient follow-up from higher authorities, no enforcement mechanisms, and lack of political will to prioritize DRF implementation. This finding aligns with a study in Khartoum State Sudan and that in Nigeria which demonstrated that political commitment is essential for long-term DRF performance as it fosters accountability at all levels [3,9]. The absence of commitment manifests in inadequate dissemination, lack of training, failure to address contradictory policies, and absence of monitoring systems. Without strong administrative commitment, even well-designed guidelines cannot be effectively implemented.

Limitations: this study has several limitations. First, social desirability and institutional-response bias may have influenced participant responses. To minimize social desirability and institutional-response bias, the interviewer established an academic, non-evaluative stance and clarified the study was not a government audit. Anonymity was assured, interviews were conducted in private settings, and open-ended, non-judgmental probing questions were used. Second, the 50-60% exemption burden figure was based on participant estimates and facility registers, not formal econometric audits. Third, the qualitative design with a small sample size (n=12) limits generalizability, though qualitative research prioritizes depth over breadth. Fourth, the study interviewed only CHMT and FHMT members, excluding lower-level facilities and users. Finally, findings represent participant perceptions from two districts and may not reflect national trends.

Recommendations: based on the study findings, we recommend: i)Training and further dissemination of the guideline should be conducted to enhance awareness and knowledge among districts and health facilities; ii)Primary health care facilities should be empowered and facilitated to operate separate bank accounts for DRF as required by the guideline to facilitate adherence, monitoring, and evaluation of fund progress. iii)Further evaluative studies should be conducted to determine the extent and patterns of implementation of the DRF guideline.

Conclusion     

This qualitative exploration suggests that implementation of the 2020 drug revolving fund guideline in public primary health facilities is constrained by low policy awareness, structural policy contradictions between national financial regulations and health guidelines, absent monitoring tools, and uncompensated exemption burdens. Findings indicate that frontline healthcare workers operate under conflicting directives that impede financial segregation and automated tracking. Inter-ministerial policy alignment between the Ministry of Health, PO-RALG, and the Ministry of Finance, alongside targeted capacity building, represents an important pathway toward supporting DRF scheme execution.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Marco Mazanzagari: conception, design, data collection, analysis, drafting manuscript. Douglas Ndeki: review proposal design, data collection, transcription, data analysis, and manuscript write-up. Phares Mujinja: reviewed the proposal design, data analysis, research report, and manuscript final draft. Fransiscko Fundi: contributed to technical and statistical expertise, proofreading, and manuscript review and formatting. All the authors have read and agreed to the final manuscript.

Acknowledgments     

The authors thank the District Executive Directors of Magu and Kwimba Districts for permission to conduct this study, the Council Health Management Teams, Facility Health Management Teams, and all study participants for their valuable contributions.

Tables     

Table 1: characteristics of council health management teams and facility health management teams participated in the in-depth Interviews in Kwimba and Magu Districts, Mwanza Region, Tanzania (N=12)

References