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June 2020
This publication was produced for review by the United States Agency for International Development. It was
prepared by the Public Sector Systems Strengthening (PS3) Activity located in Dar es Salaam, Tanzania, under
Contract AID-621-C-15-00003 with USAID/Tanzania. The USAID/Tanzania Public Sector Systems Strengthening
Activity (PS3).
PUBLIC SECTOR SYSTEMS STRENGTHENING
(PS3) IN TANZANIA
FINAL REPORT
II
The USAID/Tanzania Public Sector Systems Strengthening (PS3) Activity’s overarching goal is to support the
Government of Tanzania to strengthen the public system to promote the delivery, quality, and use of services,
particularly for underserved populations. Led by Abt Associates, PS3 is implemented in partnership with Benjamin
William Mkapa Foundation, Broad Branch Associates, IntraHealth International, Local Government Training Institute,
Tanzania Mentors for Action, University of Dar es Salaam, and Urban Institute.
June 2020
Contract No: AID-621-C-15-00003
Submitted to: Elizabeth Williams, Contracting Officer Representative
Cover Photos:
Top left: A Ward Education Coordinator from Buhigwe District in Kigoma region trains teachers at a primary school on how
to manage funds at their facility (Photo Credit: John D. Lyimo, True Vision)
Top right: A Ward Education Coordinator (left) from Kigoma trains an accountant and a nurse at a health facility on the use of
Facility Financial Accounting and Reporting System (FFARS) (Photo Credit: PS3)
Bottom left: A Ward Education Coordinator from Mbeya City (left) trains a teacher and an accountant from Majengo Primary
School in Mbeya on the use of FFARS (Photo Credit: PS3)
Bottom right: A Doctor in Buhigwe DC Kigoma, checking the condition of a sick child in one of Health facilities in Kigoma
region (Photo Credit: John D. Lyimo, True Vision)
DISCLAIMER The contents of this report are the sole responsibility of the PS3 Activity and do not necessarily reflect the views
of USAID or the United States Government.
III
ACKNOWLEDGEMENTS: All PS3 staff listed below would like to express our gratitude to the Government of Tanzania, USAID, and our partner organizations for the opportunity to contribute towards increased equity, efficiency, and improved
management of front-line services particularly for underserved populations in Tanzania. Government of Tanzania institutions
and staff demonstrated their high level of capacity and commitment on a daily basis as we worked closely together in teams that
were based on trust and mutual respect. We would like to thank USAID for its constant support and contribution to a new
strategy of strengthening cross-sectoral public financial management systems to improve delivery of services to citizens and
communities in all public sectors. Finally, all PS3 staff appreciate the support of our respective corporations or organizations,
including Abt Associates, Benjamin William Mkapa Foundation (BMF), Broad Branch Associates, IntraHealth International, Local
Government Training Institute (LGTI), Tanzania Mentors for Action (TMA), University of Dar es Salaam (UDSM), and the
Urban Institute.
Abdul Kitula
Abel Kundy
Ahamad Chiallo
Albart Fuluge
Ally Nkullo
Aloyce Maziku
Aloyce Msigwa
Aloyce Mwasuka
Amina Rajabu
Anikija Philipo Muze
Anna Nakaza
Anthony Kilale
Anthony Kimolo
Atuganile Jonas
Baraka Mwambene
Bernard Kilembe
Bethany Tomala
Bunto Mbozi
Charles Cadwell
Charles Chinuno Magoti
Christopher Ndiu
Chrispinus Melkiory
Christina Karia
Christine Godfrey
Christine Malembeka
Conrad Mbuya
Damian Mwamwongi
Daniel Ngowi
David Masanja
David Thomas Olelaput
Desderi Wengaa
Elibariki Kanakonko
Elineema Kisanga
Ellen Mkondya-Senkoro
Emilyo Mhema
Emma Liberatus
Emmanuel Malangalila
Eusebi Isidor Kapilima
Eva Kinunda
Faith Joel Shimba
Fenohasina Rakotondrazaka Maret
Fina Maziku
Flora Kessy
Françoise Armand
Frank Kachinga
Gemeni Mtei
Geofrey Lufumbi
Geofrey Nyombi
Gideon Muganda
Giovanni Di Piazza
Gladys Mkuchu
Govian Aiti
Hellen I. Nyagwa
Herbert Gondwe
Jacqueline Sombe
James J. Mungai
James Kabagile
Jean Margaritis
Jehovaness Aikaeli
Jenna Wright
Joel Mabula Shimba
John Mtui
Josephine Kimaro
Joyce Mfinga
Kokusima Clement
Leah Mwainyekule
Lemayon Melyoki
Lucy Mphuru
Lukelo Mhenga
Madesho Madesho
Maganga Magongo
Majiga Roberts
Martin Matle Lawi
Mary Peter Kasonka
Matiko Machonchoryo
Mgengeli Ngwananyamate Langalanga
Milton Ndossi
Miraji Mohamed Mpalu
Muhaned El Zein
Nazar Sola
Neema Kimey
Nseya Lameck Kipilyango
Otieno Osoro
Pastory Sekule
Paul Amanieli Chikira
Paul Michael Nandrie
Pelestian Masai
Per Tidemand
Perpetua Ngogo
Peter Kilima
Peter Maganga
Pima Mansela
Prisca Mbeswa
Prosper Mbena
Rahel Sheiza
Rahma Musoke
Ramadhan Mseya
Remmy Moshi
Rena Eichler
Renatus Mashauri
Restituta Masao
Revocatus Mtesigwa
Robert Mhongole
Rose Mangalima
Samuel A. Mashindike
Samuel Mwantingo
Samwel Ilkombe
Sarah Dominis
Scholastica Komba
Sheila O'Dougherty
Shishira Henry Mnjokava
Simon Mabagala
Stephen Kirama
Stewart Meta
Sudi Abubakari
Suma Kaare
Susan E. Muro Towo
Sylivia Kirenga
Tadeo Mboma
Veronica Ramos
Victor Pantaleo Msoma
Wabeja Samson Mahalu
Wakili Mtebe
Wilfred Msenji
Yohana Mwenisongole
Zakhayo Mahindi Simon
Zawadi Dakika
IV
TABLE OF CONTENTS
ACRONYMS ........................................................................................................................................ VII
EXECUTIVE SUMMARY .................................................................................................................. 1
1. KEY INTERVENTIONS .......................................................................................................... 8
1.1 Direct Facility Financing ......................................................................................................................................... 8
1.2 Planning, Budgeting, and Reporting (PlanRep System) ............................................................................... 10
1.3. Facility Financial Accounting and Reporting System (FFARS) ................................................................. 12
1.4. Workload Indicators of Staffing Need (WISN) plus Prioritization and Optimization Analysis
(POA) 13
1.5. Roles and Relationships ......................................................................................................................... 15
2. SYSTEM FUNCTIONS FOR SERVICE DELIVERY ................................................... 19
2.1 Information Systems ........................................................................................................................ 19 2.1.1 LGA Epicor System ........................................................................................................................................................... 19 2.1.2 Local Government Revenue Collection Information System (LGRCIS) ........................................................ 20 2.1.3 GOT Health Operations Management Information System (GoTHOMIS) ................................................. 21 2.1.4 Interoperability and Integrated Monitoring and Evaluation System (iMES) .................................................. 22 2.1.5 Local Area Networks and Help Desk ........................................................................................................................ 24
2.2. Finance ................................................................................................................................................... 24 2.1.1 Output-Based Payment and Single National Health Insurance (SNHI) .......................................................... 25 2.1.2 DFF Management ............................................................................................................................................................... 27 2.1.3 Service Outputs .................................................................................................................................................................. 28 2.1.4 Financial Reports and Resource Tracking ................................................................................................................. 29
2.3 Human Resources .............................................................................................................................. 30 2.1.5 New Staff Orientation...................................................................................................................................................... 31 2.1.6 Customized Retention Strategies ................................................................................................................................ 32 2.1.7 Open Performance Review and Appraisal System (OPRAS) ............................................................................. 33 2.1.8 Personnel Records ............................................................................................................................................................ 34
2.4 Governance and Citizen Engagement ....................................................................................... 35 2.1.1 Websites ............................................................................................................................................................................... 36 2.1.2 Complaints Management ................................................................................................................................................. 37 2.1.3 LGA Councilor Training .................................................................................................................................................. 38 2.1.4 Strengthening Committee Functioning ...................................................................................................................... 39 2.1.5 LGA Financial Management and Accounting ............................................................................................................ 39
3. COLLABORATIONS ............................................................................................................. 40
4. OPERATIONS RESEARCH AND M&E .......................................................................... 41
4.1 Operations Research ............................................................................................................................................ 41
4.2 M&E ............................................................................................................................................................................ 43
V
5. COMMUNICATIONS ............................................................................................................ 44
6. PROGRAM MANAGEMENT .............................................................................................. 46
7. CHALLENGES & WAY FORWARD ............................................................................... 47
7.1 Challenges ................................................................................................................................................................ 47
7.2 Way Forward .......................................................................................................................................................... 48
ANNEXES ............................................................................................................................................. 50
Annex 1: PS3 Indicators Target and Results .............................................................................................................. 50
Annex 2: PS3 Contractual Deliverables....................................................................................................................... 54
Annex 3: Contract and Financial Management .......................................................................................................... 55
Annex 4: Local NGO Table ............................................................................................................................................. 56
VI
TABLE OF EXHIBITS
Exhibit 1: Transforming Service Delivery by Igniting Facility Management ....................................................................................................... 1 Exhibit 2: Major GOT and PS3 Accomplishments by Key Intervention ............................................................................................................ 8 Exhibit 3: PS3 provided the platform for GOT-led national scale-up of FFARS ............................................................................................ 16 Exhibit 4: Impact of Information System Interventions at the Facility Level ................................................................................................... 19 Exhibit 5: System Interoperability through Muungano Gateway and Health Information Mediator ........................................................ 23 Exhibit 6: Impact of Finance Interventions at the Facility Level .......................................................................................................................... 25 Exhibit 7: New Intersection of PFM and Sector Service Purchasing/Provider Payment .............................................................................. 25 Exhibit 8: Impact of HR Interventions at the Facility Level ................................................................................................................................ 30 Exhibit 9: Impact of Governance and Citizen Engagement at the Facility Level ............................................................................................ 35 Exhibit 10: PS3 Collaborations with USAID Activities and DP Projects ......................................................................................................... 40 Exhibit 11: PS3 Results Framework ............................................................................................................................................................................ 43 Exhibit 12: Cover Pages of the Joint PS3 and PORALG Newsletters .............................................................................................................. 45 Exhibit 13: PS3 Regional Clusters ............................................................................................................................................................................... 46
VII
ACRONYMS
BMF Benjamin William Mkapa Foundation
CCHP Comprehensive Council Health Plan
CDD Community Development Department
CFR Council Financial Report
D4D Data for Development
DeL Distance e-Learning
DFF Direct Facility Financing
DHIS2 District Health Information System 2
DICT Department of Information and Communication Technology
DP
eGA
Development Partner
Electronic Government Agency
eLMIS Electronic Logistics Management Information System
e-OPRAS electronic Open Performance Review and Appraisal System
FFARS Facility Financial Accounting and Reporting System
FGC Facility Governance Committee
FY Fiscal Year
GHSC
GIZ
Global Health Supply Chain
German Agency for International Cooperation
GIAMIS Government Internal Audit Management Information System
GOT Government of Tanzania
GoTHOMIS Government of Tanzania Health Operations Management Information System
HBF Health Basket Fund
HCMIS Human Capital Management Information System
HIM Health Information Mediator
HMIS Health Management Information System
HR Human Resource
iCHF Integrated Community Health Fund
ICT Information and Communication Technology
iMES Integrated Monitoring and Evaluation System
LAN Local Area Network
LGA Local Government Authority
VIII
LGRCIS Local Government Revenue Collection Information System
LGTI Local Government Training Institute
M&E Monitoring and Evaluation
MOEST Ministry of Education, Science, and Technology
MOFP Ministry of Finance and Planning
MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children
MSD Medical Stores Department
NHIF National Health Insurance Fund
OPRAS Open Performance Review and Appraisal System
OR Operations Research
P4H Providing for Health
PEPFAR President’s Emergency Plan for AIDS Relief
PFM Public Financial Management
PFMRP Public Financial Management Programme
POA Priority Optimization Analysis
POPSMGG President’s Office, Public Service Management and Good Governance
PORALG President’s Office, Regional Administration and Local Government
PS3 Public Sector Systems Strengthening
RBF Results-Based Financing
RS Regional Secretariat
RSSH Resilient Systems Strengthened for Health
SNHI Single National Health Insurance
UDSM University of Dar es Salaam
UHC Universal Health Coverage
USAID United States Agency for International Development
WDC Ward Development Committee
WISN Workload Indicator of Staffing Need
1
EXECUTIVE SUMMARY
The Public Sector Systems Strengthening Activity (PS3) was a five-year USAID-funded activity
that helped the Government of Tanzania (GOT) strengthen key multi-sectoral systems to
stimulate improved delivery, quality and use of public services, particularly for underserved
populations. PS3 focused on Local Government Authority (LGA) systems to promote inclusive
and evidenced-based planning, management, and implementation of services across sectors. PS3
worked directly in 13 of Tanzania’s 26 regions and 93 of the 185 LGAs, with GOT and other
development partners (DP) cost-share expanding implementation of strengthened national
systems to the remaining 13 regions and 92 LGAs. PS3 LGAs were differentiated by 26 Phase I
and 67 Phase II LGAs, with some higher intensity interventions implemented only in Phase I LGAs
(selection based on poor indicator results within their regions). PS3 was led by Abt Associates in
partnership with Benjamin William Mkapa Foundation (BMF), Broad Branch Associates,
IntraHealth International, Local Government Training Institute (LGTI), Tanzania Mentors for
Action, University of Dar es Salaam (UDSM), and the Urban Institute. PS3’s key GOT partners
were: President’s Office, Regional Administration and Local Government (PORALG), Regional
Secretariats (RS), LGAs, service providers (health facilities and schools), President’s Office Public
Service Management and Good Governance (POPSMGG), Electronic Government Agency
(eGA), and Ministry of Finance and Planning (MOFP). This final report covers the project period
from July 29, 2015 to July 28, 2020.
Exhibit 1: Transforming Service Delivery by Igniting Facility Management
2
PS3 energized transformational change, increasing access for all Tanzanians to more
equitable, efficient, and high quality public sector services, particularly in health and
education. See Exhibit 1. Two basic assumptions drove the PS3 strategy: 1) it is difficult to
improve services without sufficient human and financial resources at the service delivery level;
and 2) it is hard to manage service providers well if systems do not extend beyond LGAs to
facilities. PS3 therefore worked with GOT to establish three system dynamics critical to the
delivery, quality and use of public sector services, particularly for underserved populations:
▪ Money to facilities. Changing the way money is disbursed means facilities receive financing directly based upon their service outputs. This breathes life into facilities, enabling
management entities to determine and procure the best mix of inputs, and empowering both
facility staff and governing committees to improve delivery of priority services to the citizens
and communities they serve.
▪ Interoperable systems to facilities. Management systems are the foundation for service delivery. Strengthened cross-sectoral systems extended to health facilities and schools ignites
the ability of providers and managers to perform basic management functions (e.g., plan,
budget, account, and report), make informed decisions, fulfill their role effectively, and
improve management practices. Extended system access also improves facility visibility,
transparency, autonomy, accountability and efficiency.
▪ Public workers to facilities. Using evidence to prioritize which facilities need staff, most
based on workload increases efficiency, equity and management of services.
PS3 KEY INTERVENTIONS
Centered on these three system dynamics, GOT and PS3 worked together to implement four
key interventions. These are summarized below and discussed in detail in Section 1 of the report.
1. PS3 helped GOT to change the allocation of money to facilities by shifting to output-
based direct facility financing (DFF). GOT and PS3 worked together to support DFF implementation, strengthening both the purchasing (financing) elements and supporting facilities
to manage the funds they received to deliver better services. PS3 helped GOT send funds directly
to facility bank accounts and better match payment to priority services and populations. As a
result, all 24,229 Tanzania Mainland health facilities and schools now receive DFF funds with the
autonomy to procure inputs and produce service outputs desired by their clients, citizens, and
communities. GOT and PS3 have broken a long cycle of disengagement among front line service
providers and public workers from their jobs and the services they render by unleashing the
power of facilities to make decisions in the best interests of the people they serve. This
transformation is one of PS3’s proudest achievements and will have a long-lasting impact on
Tanzania’s population. Furthermore, increased funding to facilities re-energized both health
facility and school governing committees (FGCs). Visible resources flowing into communities
motivated FGCs to hold meetings more often and engage with their communities. Ultimately,
FGCs were empowered to open 24,229 new civic spaces in Tanzania for engaging citizens about
the services that matter to them in health care and education.
2. PS3 supported GOT to strengthen and extend two interoperable cross-sectoral systems,
PlanRep and the Facility Financial Accounting and Reporting System (FFARS), to the
service provider level. To ensure robust management of DFF, GOT and PS3 redesigned the
inefficient stand-alone PlanRep system and converted it to web-based cross-sectoral planning and
3
budgeting, developed the new FFARS for accounting and financial management, made the two
systems interoperable, and extended facility access to them. These two systems are public
financial management (PFM) bookends, helping facilities to better plan and account for their funds.
GOT, other DPs, and PS3 rolled out PlanRep and FFARS to all 185 LGAs and 24,229 public health
facilities and schools. PlanRep was used to develop, review, and approve plans and budgets for
2018/19 and 2019/20—for the first time, Tanzania had a national sector-wide and functioning
web-based planning, budgeting, and reporting system. PlanRep efficiency gains were documented
by a GOT, Data for Development (D4D), and PS3 analysis showing 48% savings in administrative
costs related to automated review and approval of plans, and 31% time savings in planning and
budgeting processes. These massive efficiency gains means more resources to deliver services
and meet the needs of previously underserved populations.
FFARS is a new accounting system used to manage facility revenue and expenditure, including
financial report generation. FFARS use in all health facilities and primary and secondary schools
(measured by active uploading of data) accelerated from 26.1% of facilities at the end of the first
quarter of implementation (September 2017) to 93.2% by June 2018. This dramatic acceleration
exemplifies GOT ownership, LGA and facility capacity, and DP collaboration. From the first to second year of implementation, there was a concomitant increase in average health facility
revenue of 48% for 5,459 facilities in all regions, demonstrating better use of existing resources.
3. PS3 helped GOT change staff allocation and distribution to facilities based on evidence
of priority needs, with public health workers better matched to service workload. In the
context of too few health workers to meet the country’s needs, Workload Indicators of Staffing
Needs (WISN) plus Prioritization and Optimization Analysis (POA) ensures that facilities with
the greatest need have staff distributed to them first. PS3 with GOT and Touch Foundation used
the world’s first WISN plus POA to allocate 6,180 new staff to health facilities based upon the
needs of beneficiaries. In 2018, when WISN plus POA results were fed back to the national,
regional, and LGA levels, they were widely acclaimed for helping improve human resource (HR)
allocation and distribution. In addition, District Executive Directors were encouraged by a letter
from PORALG to LGAs to use WISN plus POA to inform staff distribution decisions, PS3
capacitated LGAs, and all LGAs subsequently used the system.
4. PS3 worked with GOT to establish the roles and relationships required for service
delivery improvement, ownership, and institutionalization for sustainability. With the shift
to DFF and extension of PlanRep and FFARS to the facility level, the roles and relationships
between LGAs, facility management, and FGCs changed. PS3 helped facilitate this realignment in
roles and relationships, contributing to increased facility autonomy and accountability for
improved management and service delivery. National level roles and relationships also shifted,
and PS3 supported this realignment, including ensuring the innovative and catalytic nature of
information technology was incorporated into improving functional and sector management of
programs and services. In addition, the health sector established purchasing (financing) and
provision (management) roles and relationships, and PS3’s support enabled the introduction of
single national health insurance (SNHI) moving towards universal health coverage (UHC).
To build deep country ownership and facilitate Tanzania’s journey to self-reliance, PS3 worked
hand-in-hand with GOT from the outset to identify problems, establish priorities, and implement
responsive solutions. GOT and PS3 institutionalized systems for sustainability focusing on: 1)
management of strengthened systems by GOT; 2) routine use of strengthened systems by public
4
sector staff; 3) development of distance education courses on using systems and interventions
for public sector staff; and 4) integration of courses on financial management and strengthened
systems into undergraduate and graduate education. An indicator of ownership and success was
that GOT and other DPs leveraged USAID funding to cost-share and implement strengthened
systems in Tanzania’s remaining 13 regions and 92 LGAs not supported directly by PS3. Through
establishing a true partnership with GOT on shared development goals, USAID saw a 200%
return on investment and extended DFF and strengthened systems nationwide.
Before GOT and PS3 reforms and systems strengthening, LGA and facility levels faced challenges
as portrayed in Exhibit 1 and inherent in the basic assumptions: the dark and empty building of a
front-line service provider without sufficient human and financial resources to deliver equitable
and high quality public services to citizens and communities particularly underserved populations.
After the reforms and systems strengthening, DFF and interoperable PlanRep and FFARS PFM
systems have transformed health facilities and schools into entities with a foundation of better
basic governance and management, and the autonomy and accountability to continuously and
sustainably improve delivery of public services for their beneficiaries (patients and students).
SYSTEM FUNCTIONS FOR SERVICE DELIVERY In addition to the key interventions described above and in Section 1, PS3 focused on four key
system functions: information systems, finance, HR, and governance and citizen engagement.
These system functions are prerequisites to and underpin extension of interoperable systems to
the facility level, shifting human and financial resources to facilities, and increasing the efficiency
and management of service delivery at LGA and facility level. Primarily strengthening LGA level
systems, comprehensive, integrated and synergistic interventions energized LGAs and enabled
facilities to improve management and delivery of public sector services. The results are
summarized below and discussed in detail in Section 2 of the report.
Information systems. PS3 strengthened LGA capacity to operate and use the Local Government
Revenue Collection Information System (LGRCIS), including a mobile application. In the 93 LGAs
supported by PS3, tax revenue collected by LGAs increased substantially (by 3.7% in 2017, 16%
in 2018, and 35% in 2019). GOT and PS3 also strengthened Epicor to account for the receipt and
expenditure of funds in LGA bank accounts, and made it interoperable with PlanRep, LGRCIS
and FFARS. GOT cost-shared with PS3 to extend Epicor to all 185 LGAs; nearly 90,000
transactions were recorded in the first two months of use. In sector-specific information systems,
GOT and PS3 strengthened the facility-level GOT Health Operations Management Information
System (GoTHOMIS), making it interoperable with the health management information
system/district health information system (HMIS/DHIS2), the electronic logistics management
information system (eLMIS), and the National Health Insurance Fund (NHIF) claims management
system. In 2019, GoTHOMIS Standard was operating in 10% of health facilities nationwide (522).
GoTHOMIS Lite was developed by GOT and PS3 programmers and available for all health
facilities without sufficient IT infrastructure to operate GoTHOMIS Standard (user testing
performed, system working in 30 facilities by the end of PS3, and nationwide downloading and
use expected later in 2020).
PORALG and PS3 made the strengthened cross-sectoral PFM systems interoperable through the
Muungano Gateway information mediator, enabling information exchange to drive management
improvements and efficiency gains. Data exported to the integrated monitoring and evaluation
5
system (iMES), including a public portal, enabled better access to and use of data. Extension of
local area networks (LANs) and establishment of a PORALG Help Desk provided the tools and
support needed for routine system use.
Finance. PS3 supported the shift to output-based payment in 5,459 health centers and
dispensaries in all 185 LGAs in Tanzania, collaborating with multiple stakeholders to train
approximately 13,000 national, regional, LGA, and health facility staff on how to use and manage
their DFF funds. By the end of PS3, 98.5% of health facilities were paid through the new or
improved output-based payment systems. PS3 also supported the shift towards results-based
financing (RBF) in health, and helped establish the foundation for SNHI. In education, PS3 provided
technical assistance to improve the output-based payment system by switching from a flat fee per
student to a formula driven budget neutral system similar to the health sector with school
payments adjusted for need as defined by number of students enrolled, and adjusted for equity
as defined by LGA poverty index, distance to LGA center, and number of students with disabilities
(ministries of education and finance are engaging in dialogue about the budget for implementation
of the new approved formula).
By making FFARS interoperable with other key PFM systems, PS3 enabled automatic and on-time production of key LGA reports—the percentage of LGAs submitting complete reports on time
rose from 43.8% at baseline to 100% in Year 4. Lastly, PS3 provided technical assistance to the
Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) to
finalize National Health Accounts analysis and reporting for FY2013/14 to 2017/18, and helped
institutionalize the process into the ministry by building capacity to use the NHA tools.
Human Resources. In July 2017, the PORALG Minister launched nationwide implementation of
a new staff orientation manual. PS3 mentored LGAs on using the approved manual, and by the
end of PS3, 55.4% of new staff had received a job orientation using the manual, a process that
was led largely by LGAs themselves. This percentage will increase with deployment of LGTI’s
new staff orientation distance e-learning (DeL) course developed as part of PS3. In addition, a
technical working group of GOT and PS3 staff developed, tested, and refined a package of tools
to empower LGAs to develop their own staff retention strategies. It was deployed through PS3
mentors, supporting LGAs to design their retention packages focused on the needs of their staff
and unique environment. All 26 PS3 Phase I LGAs developed and approved their own customized
retention strategies, and retention rates in these LGAs, calculated one year after the new staff
were posted, increased from 65% in Year 3 to 99% in Year 4.
PS3 also helped strengthen the public sector appraisal system, including improving how teacher’s
Open Performance Review and Appraisal System (OPRAS) goals were set, and developing e-
OPRAS and making it interoperable with the redesigned human capital management information
system (HCMIS) to automate performance management. A combination of strengthening bottom-
up LGA manual personnel records management, automating personnel records in e-Office, and
incorporating employee actions and benefits into the redesigned HCMIS, contributed to
improved performance and a broader approach to HR management.
Governance and Citizen Engagement. GOT and PS3 developed and launched the Government
Website Framework in 2017 for RS/LGA websites to share information with citizens and improve
internal communication and management. By late 2018, 71% of LGAs published their local budget
summary on their website, almost half published local expenditures and revenue, and almost a
6
third uploaded forms for public workers (e.g., vacation forms), which increased financial
transparency and convenience for staff and businesses. PS3 also helped to develop and implement
mechanisms for strengthening and extending citizen feedback and complaints management. The
percentage of Phase I LGAs with a complaints management desk/office increased from 34.6% to
73.1%, and the percentage of LGAs with a functioning complaint mechanism rose from 46.2% at
baseline to 87.1%.
LGA councilor training increased the governance capacity of 2,949 councilors and served as the
PS3 entry point for other interventions in the 93 LGAs. In order to strengthen LGA committee
functioning, PS3 developed and deployed a benchmarking tool that was used to identify gaps and
inform mentoring to address those gaps. Benchmarking scores showed an increase of 79% in
committee functioning. In addition, PORALG and MOFP worked with PS3 to reduce the number
of qualified audit opinions by improving the content of LGA accounting practices, and
strengthening procedures for yearly closure of books and final accounts preparation. The
percentage of targeted LGAs with clean audit reports increased from 25% to 96.8%. PS3 also
supported PORALG and MOFP to automate internal auditing by development of Government
Internal Auditing Management Information System (GIAMIS).
OPERATIONS RESEARCH AND M&E
PS3 worked with GOT to identify, design, and implement a number of operations research (OR)
studies to inform ongoing refinement in GOT and PS3 implementation strategies. The key OR
product was a detailed qualitative analysis of the dynamics of change in health facility and school
management and governance in the context of DFF and extension of systems (i.e., PlanRep and
FFARS) to the facility level. The overall perception among health and school in-charges, staff, and
FGCs was an improvement in their ability to manage and deliver public health and education
services to their citizens and communities, a perception that was echoed by LGA officers. PS3
also collaborated with D4D to analyze and document PS3 results, including: quantifying cost
savings and efficiency gains; analyzing revenue and expenditure trends; and identifying factors
affecting system use and sustainability. Details are contained in Section 4.
PS3’s primary M&E task was to track progress on approved M&E Plan indicators for refinement
of program interventions and USAID contract reporting. The approach is summarized in Section
4 of the report. All PS3 indicators and yearly results are contained in Annex 1.
COLLABORATIONS & COMMUNICATIONS
Section 3 of the report contains a table summarizing PS3 collaborations with USAID activities
and other DP projects. Section 5 summarizes key communication activities and support to GOT
to strengthen communication capacity. A list of contractual deliverables submitted to USAID and
uploaded to the Development Experience Clearinghouse (DEC) is included in Annex 2.
CHALLENGES
PS3 faced no major challenges throughout program implementation. However, due to the size,
complexity, collaborations, and multi-sectoral work of PS3 across all levels of government,
operational challenges arose. The joint GOT/PS3 response was to continuously focus on
efficiency, communication, management and collaboration. Where technical challenges arose (e.g.,
with simplification of WISN, or interoperability between PORALG Muungano Gateway and
MOHCDGEC health information mediator (HIM)), issues were resolved effectively through
7
dialogue, teamwork, and implementation sequencing. Ultimately, PS3’s excellent relationship with
GOT, and the project’s approach to mitigating technical and operational challenges contributed
to institutionalization (e.g. GOT ownership of systems and their use in day-to-day routine
activities), and Tanzania’s journey to self-reliance.
WAY FORWARD
Together, GOT and PS3 introduced a transformational systems strengthening strategy that
shifted money, systems, and people to over 24,000 health facilities and schools. The shift ignited
the ability of facilities to operate as management entities with the mandate and authority to better
serve their clients. While PS3 made great strides in improving the foundation of cross-sectoral
PFM systems and processes, and improving health and education front-line service delivery, next
steps to deepen the results of the productive GOT and PS3 partnership should include:
1) Further strengthening to consolidate the gains made in public sector management in the health
and education sectors;
2) Extending into new institutions and sectors, and reaching more citizens; and
3) Continuing the handover of financial and programmatic responsibility for PS3 areas of support
to ensure Tanzania is able to sustain delivery of efficient, equitable, and responsive quality services particularly for underserved populations.
8
1. KEY INTERVENTIONS
Key GOT and PS3 interventions arose from the basic premises underlying PS3’s design: 1) extend
systems to the service provider level; and 2) shift human and financial resources to facilities. DFF
and the shift to output-based payment empowered facilities with the autonomy to use PlanRep
to plan and budget based on their community priorities, and FFARS to use funds, and account for
and report expenditures. FFARS was implemented in July 2017 and PlanRep in July 2018. The
Health Basket Fund (HBF) shifted to output-based payments directly to health facilities in
December 2017, joining education sector funds flowing through DFF. Other key interventions
were WISN plus POA, which helped inform better distribution of staff to health facilities. The
combination of reforms and strengthened systems radically transformed the nature of health
facility and school management in Tanzania—see Exhibit 2. GOT and PS3 key interventions are
discussed in detail below.
1.1 Direct Facility Financing
The DFF policy started in the education sector
in Tanzania—schools were paid through a
predetermined fee per enrolled student. In
2018, the health sector also adopted DFF by
shifting general revenue HBF resources to
output-based payment for 5,459 health centers
and dispensaries in all 185 LGAs of Tanzania. GOT and PS3 worked together to support DFF
implementation, including strengthening the
purchasing (financing) elements, and supporting
facilities to better manage the funds they
received (see Section 2.2, “Finance”).
The introduction of DFF changed the landscape
for public facilities dramatically. With money
sent directly to health facility and school bank
accounts, facilities could for the first time plan,
budget, and manage their own resources to
deliver accessible and high quality services and
better meet the needs of their beneficiaries. In
addition, facilities received funds based on a
formula that calculates payment for service
outputs, replacing rigid line-item budget
payments for inputs (e.g., drugs and supplies).
For example, outputs in health include the
essential service package and its sub-outputs
(immunize children, and deliver maternal,
newborn, and child health, family planning,
malaria, HIV, and tuberculosis services). DFF
provides more transparency, certainty, and
predictability in funding, and increases
Direct facility financing—established
DFF and shifted to output-based payments,
increasing facility autonomy and
accountability, and energizing public service
providers to take ownership of improving
their delivery of services.
PlanRep and FFARs—strengthened and
extended interoperable public management
systems to 24,000 health facilities and
schools in Tanzania, improving visibility,
increasing transparency, and helping facilities
manage resources better.
WISN plus POA—created a system for
allocating new staff to facilities based on
evidence and for prioritizing staff allocation
based on need, and used the system to
allocate 6,180 new staff to health facilities.
Roles and relationships—strengthening
systems, including sequencing and
institutionalization, contributed to bottom-
up realignment of roles and relationships
around facility autonomy and accountability,
LGA support and oversight, and regional
and national policies, guidelines, and support
to improve management and delivery of
services.
Exhibit 2: Major GOT and PS3 Accomplishments
by Key Intervention
9
accountability—health facilities are more accountable for
managing their funds to determine the most efficient and
effective mix of inputs to procure, and for more
appropriate accounting, financial management, and
reporting. Financial incentives are an additional advantage
of output-based payment, giving facilities the opportunity
to increase their revenue if they are motivated and
produce service results consistent with incentives. As
documented in the PS3 Facility OR Study, DFF also
impacted positively on HR management—76% of health
facility and school staff interviewed reported positive
changes in their working conditions over the previous
year which motivates staff to improve their performance
and quality of services to beneficiaries. DFF also had a
substantial impact on FGCs and the relationship between
facility management and governance:
FGCs now fulfill their planning and oversight functions more effectively. Planning
and budgeting is conducted jointly by FGCs and facility management. Previously cash flow to
health and education facilities was indirect and unreliable, inhibiting effective planning and
oversight functions. DFF and strengthened systems such as PlanRep extended to facilities (see
below) provides a motive for improving governance and management functions—increased
access to information and more visible resources provides FGCs with a tangible role in planning and
budgeting, and enables them to execute their oversight
role more effectively. This includes through regular
meetings to scrutinize and approve plans and budgets,
oversee implementation, approve procurement requests,
and receive and review financial reports from facility
management.
FGCs/boards are now empowered, more
active, energized, and communicate confidently
with and respond to citizens. DFF empowers FGCs
to engage citizens more actively using both formal and
informal processes because they have more to discuss. In
effect, DFF provides an avenue to increase the civic space
surrounding health facilities and schools. Meetings are
held more often, and communication within facilities and
between facility and other levels improved, as did
relationships between FGCs and staff. FGCs now feel
more engaged in facility planning and budgeting
processes, they can represent community needs better, and are able to report back to their community (and
government) to account for the funds they oversee. In
addition, improved communication and transparency
“Our ability to provide services has
improved significantly. We are now
able to purchase goods based on
needs of the facility and thus provide
good and quality services.”
Dispensary In-Charge, PS3 OR Study.
“Now DFF and PlanRep system
disburses all the funds directly to us
promptly, which has improved
service delivery and motivated staff
to continue to work in the health
center.” Health Center In-Charge,
PS3 OR Study
“In the past, we could go for six
months without meeting. Now if
there are issues the in-charge calls a
meeting immediately.”
“Before the recent initiatives were
implemented, it was difficult to even
call members of the committee to a
meeting. Even when they met, only a
few activities that were agreed on
were implemented due to limited
financial resources.”
“Committee has increased
involvement and has a bigger role in
making decisions on expenditures
since more money has been
received.”
“DFF has made FGC involvement in
planning and budgeting more
relevant as it is based on a more
realistic resource envelope controlled
by the facility rather than a resource
envelope controlled by the LGA.”
10
better positions FGCs to mobilize their communities for in-kind or cash contributions to
complement GOT efforts.
DFF also established the financing foundation required to implement SNHI and move towards
UHC by ensuring that health facilities were prepared to receive and manage insurance payments. .
1.2 Planning, Budgeting, and Reporting (PlanRep System)
Until 2018, LGAs were responsible for developing annual plans and budgets for facilities.
Information was aggregated at the LGA level and often not communicated to facilities, making it
difficult for facilities to plan, budget, and manage
services for their beneficiaries. As Tanzania
introduced DFF, GOT also invested in systems
at the facility level to enable them to manage
their resources better. PlanRep is a web-based,
interoperable, cross-sectoral system used across
the public sector—it replaced a system that was
fragmented by sector, standalone, and error-
prone. At the start of FY2018/19, all 185 LGAs
and 24,229 public health facilities and schools in
Tanzania began to use PlanRep to implement
their approved plans and budgets. This was
achieved through a partnership between
PORALG, RS, LGAs, POPSMGG, eGA, MOFP,
sector ministries, other DPs, and PS3.
Extension of PlanRep to the facility level enabled management and governing committees to
directly plan and budget for the services they provided, including engaging citizens to ensure plans
were responsive to community needs. With the inclusion of “service outputs” in PlanRep, facilities
could develop plans and budgets to leverage fully the payment formulas and incentives in DFF. In
addition, PlanRep can exchange information with other key PFM systems, including LGRCIS, the
LGA Epicor accounting system, and FFARS. Together, these four systems and their ability to
exchange information, creates a strong foundation for public sector service management by
improving business processes of LGAs and facilities.
PlanRep implementation included two phases of activities:
1) System design and development culminating in a massive nationwide deployment
operation—this included: dialogue, user requirements gathering, analysis, project charter
development, design, programming the software and its interoperability, system
administration, development of support materials, user testing, and deployment training
through regional workshops that included GOT cost-share.
2) Mentoring and system refinement enabling continuous improvement in LGA and facility
planning and budgeting—this included: mentoring across all levels of government; system
refinement and refresher training for policy and procedural changes in the yearly planning
cycle; supporting plan and budget review, including budget scrutiny to match budgets to
Prime Minister of the United Republic of Tanzania, Kassim Majaliwa Majaliwa (left) in a tête-à-tête with US Embassy Chargé d’Affaires, Inmi Patterson, during PlanRep launch in Dodoma. (Photo: PS3)
11
ceilings; incorporating program management improvements into the system (e.g., mid-year
budget reallocation, year-end budget carryover); and refinement of system and user support
materials.
PlanRep had a substantial impact on increasing efficiency:
The health sector realized substantial efficiency gains, as well as management and service delivery
improvements, by combining use of the standardized
PlanRep system with sector-specific strategies.
PORALG, MOHCDGEC, other DPs, and PS3 worked together
to revise the Comprehensive Council Health Plan (CCHP)
guideline. This included harmonization with PlanRep, extension
to the facility level, linking to health facility payment, and
emphasizing data use to inform priorities and investment
decisions. Following revision of the CCHP guideline, the
PlanRep system and its interoperability were refined. The
revised CCHP guideline and refined PlanRep were deployed on
July 1, 2020 through training and mentoring. User support and
system refinement based on user experience are ongoing.
Use of PlanRep dramatically reduced administrative costs in the public sector,
with the potential for reallocation to extend services to the underserved. PlanRep
efficiency gains were documented by a GOT, D4D, and PS3 analysis. The study revealed 48%
savings in administrative costs related to automated review and approval of plans. In the past,
LGAs would print documents and travel to the capital to defend their budgets. These administrative cost savings (e.g., for transport, per diems, printing, and photocopying) can be
reallocated to service delivery. A comparable analysis showed a 31% time-saving in planning
and budgeting, allowing LGA and facility workers to spend more time managing and delivering
services.
The budget process is more transparent as budget ceilings are entered in the system and visible
to all levels of government and institutions as they start their planning and budgeting. In addition
to efficiency gains, PlanRep budget scrutiny
ensured that total LGA and facility budgets did
not exceed MOFP ceilings. This results in more
realistic budgets, helps managers facilitate
delivery of services with more predictable
revenue streams, and helps build trust across
the public system. In summary, PlanRep
empowers LGAs and facilities to better plan
and budget, optimize their financial resources,
and deliver more accessible and higher quality
services to their beneficiaries and communities.
“We are generally very satisfied
with the choices or priorities that
facilities are making about how
to use the funds from their bank
accounts. They are based on
participatory approaches during
the planning and budgeting
exercise, including advice given
at the local government level.
Facility funds in their bank
account are being used properly
according to priorities identified
in their plans and the guidelines
provided.” LGA Respondent, PS3
OR Study
A number of books carried by LGA staff to Dodoma during the planning and budgeting process. (Photo: PS3)
12
1.3. Facility Financial Accounting and Reporting System
(FFARS)
The FFARS accounting system is used in the Tanzanian education and health sectors at the facility
level. Its introduction in 2017 went hand-in-hand with DFF and the shift to output-based payment,
underpinning the needed financial management improvements at the facility level to support DFF.
Previously health centers and dispensaries had no standard financial accounting and reporting
system, and although primary and secondary schools had paper-based accounting systems, their
operation was suboptimal. FFARS supports facilities to make purchases, record financial
transactions, produce financial reports and reconcile bank accounts. The system is accessible on
both a web-based platform and a mobile application. A manual version is also available for remote
facilities with no information technology infrastructure although the number of facilities using it
is declining as remote facilities shift to FFARS mobile application.
PORALG, RS, LGAs, MOFP, MOHCDGEC, Ministry of Education, Science and Technology
(MOEST), DP basket funders and projects, and PS3 collaborated to design, develop, and deploy
FFARS in 24,000+ health facilities and schools in all 26 regions and 185 LGAs starting July 1, 2017.
A national PORALG and PS3 expert team, as well as responsible LGA accountants and lower
local government staff (including ward education officers), deployed a cascade training and system
installation process to mentor facility staff on using FFARS. Like PlanRep, GOT and PS3 FFARS
implementation consisted of development/deployment followed by continuous improvement:
1) First phase development/deployment
activities included: user situational analysis and
requirements gathering for facility accounting
and financial management; design and
development of paper-based FFARS, including
training materials and working templates; design and development of automated FFARS; user
testing; development of administrator and user
support materials; and preparation for regional
workshops and mentoring.
2) Continuous improvement activities
included: user support and mentoring; bug-fixing;
improvement in technical functioning (e.g.
transaction posting, bank reconciliation,
procurement and internal controls, reports, and
dashboard); ongoing refinement of system and
support materials; and system enhancements and
upgrades.
PORALG and PS3 also developed and deployed
the FFARS mobile application. Accessible through
android mobile phones and tablets, the app
contains all the features of the web-based system, providing access for facilities with electricity,
computer, or internet challenges. A second upgrade was integrating FFARS with the Medical
Stores Department (MSD) Epicor-9 accounting system and eLMIS. To achieve this, PS3 worked
The FFARS Training Manual was developed by GOT and PS3, demonstrating the impact of joint efforts
13
with ICT and business process experts from PORALG,
MOHCDGEC, MSD, and the Global Health Supply
Chain (GHSC) project. Integration made budget funds
allocated to MSD by MOFP visible in FFARS, improving
the ability of facilities to plan the procurement of
medicine and other supplies. FFARS improved facility
management and operations:
FFARS simplifies record keeping, reduces paperwork, and improves the accuracy,
consistency, and timeliness of report production.
The PS3 facility OR study documented that 61% of facility managers thought FFARS made
reporting simple, accurate, transparent, and consistent, and reduced their paperwork. PS3
also monitored the percentage of LGA service providers with updated revenue and
expenditure information uploaded into the electronic FFARS. At the end of PS3, this was
97.8%. The result is admirable given that all health facilities and schools using the manual
version of FFARS had to travel to a site with the electronic version to upload their data.
FFARS improves the ability of facilities to efficiently manage, account, and report
for funds received and disbursed. There was a 48% increase in average health facility
revenue for all 5,459 facilities in all regions/LGAs of Tanzania from the first quarter of the
first year of FFARS use (FY2017/18) to the first quarter of the second year of FFARS use
(FY2018/19). While not “new” money, this analysis
of health facility and school system use
demonstrated rapid uptake of FFARS with its improved financial management processes.
In addition to the above benefits, FFARs is able to
exchange information with PlanRep, making it possible
to delineate and track funds by source, including
development funds. FFARS enables recording of
revenue and expenditures and generation of financial
reports at facility, LGA, regional, and national levels.
FFARS also provides an accountability and
transparency mechanism for LGA, regional, and
national levels, allowing these bodies to perform their
oversight functions (e.g., detecting potential misuse of
resources) and take timely action to enforce facility
compliance and accountability.
1.4. Workload Indicators of Staffing Need (WISN) plus
Prioritization and Optimization Analysis (POA)
HR shortages in health have long been a contributing factor to poor service delivery in Tanzania.
Many remote rural health facilities have insufficient health workers, while some facilities in urban
areas have more workers than they need. WISN plus POA is an evidence-based methodology,
system, and management process. WISN determines the workforce needs of health facilities by
“Managing available funds through
financial reports and expenditure
records helps in prioritizing the most
important needs at the facility
depending on the available funds. As
a result, we will improve service
delivery.” Head teacher of Makole
Primary School
Bukililo Primary School is situated 40 km
from LGA headquarters (HQ) with limited
public transport. The Head Teacher is
very happy with FFARS as it relieves him
of many tedious trips. “I have more time
to teach, attend to other school matters,
and it saves transport costs. Previously I
used to travel to LGA HQ 4-5 times per
month to request funds for recurrent
expenditure for various activities, and
most times would return only with
promises and should come back next
week.” - Bukililo Primary School Head
Teacher
14
looking at actual workload, and POA is a ranking index that helps address HR shortages by
prioritizing staff distribution to health facilities with the greatest need.
MOHCDGEC, PORALG, POPSMGG, MOFP, Touch Foundation, and PS3 undertook a complex
multi-phased WISN plus POA development and implementation process. It started in nine PS3
and non-PS3 regions (Iringa, Coast, Mara, Mbeya, Morogoro, Mtwara, Mwanza, Tanga, and
Kigoma), with cost-sharing in the non-PS3 regions of Coast and Tanga. MOHCDGEC and PS3
completed WISN plus POA training and data collection, and then disseminated a standard
package to build consensus that LGAs would use WISN plus POA for staff distribution. WISN
plus POA was tested by distributing 2,058 new health workers in five regions (Iringa, Mara, Mbeya,
Morogoro, and Mwanza). Based on experience and lessons learned, the WISN methodology to
determine workload was refined to base it on existing indicators and available data in the health
management information system (HMIS)/DHIS2. Previously the time and costs of collecting WISN
data were very high, but the simplified WISN reduced average processing time per region from
about two months to one day. In addition, variable cost savings (e.g., for travel) were substantial
as the simplified WISN analysis was done using existing data and a primary data collection visit to
each health facility was no longer required. Following WISN simplification and testing to distribute 2,058 staff, extensive national policy dialogue culminated in agreement by PORALG, POPSMGG
and MOHCDGEC to use the simplified WISN plus POA to distribute LGA staff.
When PORALG received 6,180 new health workers from
POPSMGG and MOFP, they used WISN plus POA to
inform staff allocation across LGAs, and LGAs used WISN
plus POA to inform staff distribution to facilities within
each LGA. PORALG, MOHCDGEC, Touch Foundation,
and PS3 technical teams deployed WISN plus POA through
six regional workshops. The workshops included dialogue,
technical assistance, and capacity building for all 185 LGAs
on using the simplified WISN plus POA to distribute their
new health staff. All LGAs subsequently used WISN plus
POA to inform their staff distribution decisions for these new health workers. PS3 also helped
LGAs integrate interventions for improved HR management, including new staff orientation and
personnel records management, as they distributed the new staff—see Section 2.3, “Human
Resources”.
WISN plus POA is a powerful and unique tool for making critical HR distribution decisions. In
the context of too few health workers to meet the country’s needs, WISN plus POA facilitates
prioritization, ensuring that health facilities with the greatest needs receive staff first. Budget
constraints and inadequate production meant there were never enough new health workers to
realize WISN recommendations; adding the POA methodology helped decision-makers make the
best use of available staff. WISN plus POA was selected by the President’s Emergency Fund for
AIDS Relief (PEPFAR) for inclusion in the new “PEPFAR Solutions” compendium of impactful,
data-proven implementing experiences that can serve as ‘how to’ guides for others. PEPFAR
Senior Technical Advisor for Clinical Financial Sustainability said, “We were particularly excited by
the WISN plus POA model—it was the only HRH submission we found to truly be a solution that other
countries should emulate”.
“Facilities that were in real need of
health workers were identified, and
this system will improve health
services even to those remote
facilities found in the interior, as it
will reduce the burden of work, and
balance the provision of services.”
Buhigwe LGA Health Secretary.
15
WISN plus POA has been integrated into GOT systems. LGAs can now use WISN plus POA to
analyze their own HR situation routinely, request staff, and make staff distribution decisions
without external support. In addition, central government can use WISN plus POA to plan
national level staff allocation across LGAs, and MOHCDGEC can target resources to ensure the
right number, type, and level of health workers are trained.
1.5. Roles and Relationships
Recent reforms dramatically changed the nature of business management functions and facility
operations in Tanzania, while realignment of roles and relationships solidified the foundation for
and enabled continuous improvements in facility management and service delivery. Facility
managers and staff now use their increased autonomy and accountability to focus on their core
business of managing service delivery to citizens, beneficiaries, and communities. FGCs are more
active in decision-making, oversee and guide service delivery to ensure achievement of goals and
objectives, and engage and represent citizens/communities for transparency and accountability.
LGA officers coordinate and provide support, address needs, and oversee and supervise facilities
to ensure value for money and quality services. Together, GOT and PS3 made systemic changes,
leveraged reforms, and realigned roles and relationships to improve basic management functions,
increase efficiencies, and empower front-line service providers. Specifically, moving money,
systems and the right people ignited the ability of health facilities and schools to perform the
management functions required to deliver quality services to the communities they serve. To
achieve this, the following key tenets were at the core of PS3’s implementation approach:
Support the “right institution to do the right thing;”
Strengthen existing systems, not develop parallel systems;
Develop systems jointly to build technical teams, trust, and understanding;
Sequence implementation strategically to address political economy considerations;
Use systems and information technology to catalyze reform and improvement in management
and service delivery; and
Implement strengthened systems nationwide with bottom-up user support to empower LGAs and facilities.
Key elements of PS3 implementation strategy and sequencing were a joint implementation
partnership with PS3; appropriate realignment of institutional structure, roles, and relationships;
and institutionalization for sustainability, with a focus on mechanisms for continued education.
PS3’s strategy with GOT's leadership and investment in nationwide implementation of DFF and
strengthened systems magnified USAID's investment and resulted in facilities nationwide with
improved ability to plan, budget, manage staff, procure, account, and report on public service
priorities. This is discussed further below.
1.5.1 GOT and PS3 Joint Implementation Partnership
To build deep country ownership and facilitate Tanzania’s journey to self-reliance, PS3 worked
hand-in-hand with GOT from the outset to identify problems, establish priorities, and implement
responsive solutions. Capacity building, including training and mentoring, was concrete, practical
and inherent in system design, development, deployment, use, management, and maintenance.
PS3’s inclusive approach—combined with respect for the roles of all ministries, departments, and
agencies—allowed GOT and PS3 to interweave and integrate each activity with others to leverage
16
synergies and achieve small successes that built momentum, while also sequencing activities
strategically and logically to ensure institutionalization for sustainability. The approach also
underpinned trust and ability of joint GOT and PS3 teams to be flexible and adaptive in identifying
opportunities. Furthermore, the extremely strong, productive and open relationship that PS3
established with GOT ensured ownership and catalyzed rapid nationwide implementation of high
impact interventions. PS3 also collaborated with many DP projects (see Section 3,
“Collaborations”), using respective comparative advantages to ensure each activity
complemented and was supported by other partner activities, as well as to leverage funds to the
greatest extent possible.
GOT national scale-up of FFARS illustrates the success of PS3’s partnership approach. Exhibit 3
compares changes in FFARS system use in PS3 and non-PS3 regions. During the first quarter of
implementation (July-September 2017), LGAs in PS3 regions had substantially higher use of FFARS
(40%) compared to non-PS3 regions (12%). However, this difference evaporated during the first
year of implementation. By June 2018, use in PS3-supported regions was 94% compared to 92.4%
in non-PS3 regions. Although there were many variables involved in this change, a critical factor
was GOT commitment to deploying FFARS. Progress in non-PS3 regions does not undermine investment in PS3 regions, but demonstrates the project’s success in working with GOT to
institutionalize supported activities, use learning to create momentum for nationwide
implementation, and GOT’s ownership of PS3 supported processes. This ownership was
exemplified by: supporting implementation in non-PS3 regions with GOT cost-share; mandating
its use; motivating national, regional, LGA, and facility public workers; and coordinating other
DPs to collaborate and invest budget support in this area.
Exhibit 3: PS3 provided the platform for GOT-led national scale-up of FFARS
1.5.2 Institutional Structure, Roles, and Relationships
PS3’s implementation strategy of establishing the dynamics to shift systems, money, and people
to facilities required the successful realignment of institutional roles and relationships, including:
within PORALG and with RS and LGAs; between the multi-sectoral ministries of PORALG,
POPSMGG, and MOFP; between PORALG and sector ministries, particularly MOHCDGEC; and
between MOFP and sector ministries.
17
An exemplary achievement was realignment of PORALG roles and relationships to increase
ownership of PlanRep. During the first year of PlanRep implementation (2018),
PORALG/Department of Information, Communication, and Technology (DICT) led the technical
aspects of system operation, maintenance, management, and refinement. In 2019 (the second
year of PlanRep implementation), PORALG/Department of Policy and Planning stepped up to
perform its legal responsibility and lead planning and budgeting across PORALG, RS, LGAs, and
facilities in concert with MOFP. This ownership demonstrates progress towards
institutionalization for sustainability, with a better balance between information technology
responsibilities and functional or sector program management ownership (“business process
owner” in Tanzanian terminology) for planning and budgeting across the public sector. PS3 played
an active role in this process, including involving “business process owners” in implementation,
supporting dialogue to determine appropriate separation of roles and clear definition of
responsibilities, and continuous engagement to solidify realigned roles and relationships.
A second national level example was alignment of roles and
relationships for DFF for health and SNHI. Progress included
envisioning MOHCDGEC and NHIF in the role of financier/purchaser, with PORALG, RS, LGAs, and facilities
fulfilling the role of managers/providers. Throughout, PS3
proactively engaged in dialogue to inject international
experience and best practice related to: health financing
systems vs. schemes; pooling and purchasing arrangements to
move towards UHC by increasing efficiency, equity, and
financial risk protection for the poor; and provider autonomy
and accountability to improve management and service
delivery. In addition, PS3 engaged in dialogue and supported
the PORALG Department of Health to increase efficiencies
by establishing a comprehensive DFF Unit; this institutional
restructuring helped prevent fragmentation in funding flows.
At the LGA level, as facility autonomy increased, it was
critical that the institutional structure, roles and relationships
between LGA headquarters and facilities evolved
concurrently. All GOT and PS3 interventions encompassed
the productive realignment of LGA and facility roles and relationships. This enabled the successful
implementation and institutionalization of systems strengthening, and drove public sector
management transformation and service delivery improvements.
An MOHCDGEC and DP joint field visit report contained interesting observations about the
evolution of LGA and facility roles and relationships under DFF in the health sector. LGA and
facility stakeholders felt that trust between LGAs and facilities increased due to greater openness,
transparency, and understanding of roles. Fewer complaints from stakeholders were observed,
and there was a feeling of increased shared responsibility—LGAs had previously felt
overburdened, but now felt more supported. Although realignment of roles and relationships was
still in progress at the time of writing, there was clear understanding that both the LGA and
facility levels needed to function together and effectively to deliver high quality health services.
As discussed in relation to DFF (under “Key Interventions”), directly funding facilities energized
FGCs and in-charges highlighted
increased collaboration and
improved relationships:
“Very good relationship, teamwork,
and cooperation between committee
and facility management; there is
more cooperation now after DFF
than before, more transparent now
with DFF.”
“It is important for school governing
committee members to receive
capacity building including training.
Most of us are doing our job based
only on experience. But I believe that
if we receive some training, we could
add more value to our roles and
responsibilities as FGC members.”
FGC members, PS3 Facility OR Study
18
FGCs, which contributed to realignment of roles and relationships, particularly with facility
management. The PS3 Facility OR Study gathered evidence about the evolution of these roles
and relationships in the context of DFF and extension of PlanRep and FFARS to facilities. FGC
members were asked if they were able to engage well with facility management to fulfill their
governing roles—all FGCs responded “yes”. Respondents also:
Recognized the role of DFF in realigning, strengthening, and increasing cooperation in the relationship between FGCs and facility management;
Expressed that improvements could be made, for example, by increasing transparency with
respect to sharing information on receipt and use of funds; and
Highlighted the importance of ensuring that facility financial reports were presented,
discussed, and used to inform decision-making by FGCs, village assemblies, and Ward Development Committees (WDCs).
FGC members also communicated that lack of training or orientation on their role limited their
effectiveness—see text box.
Another LGA focal point was the structure, roles, and relationships between the LGA executive
arm (District Executive Director, departments, and facilities), its political arm (District
Commissioner, council, standing committees, WDCs, and village/mtaa committees), and the
convergence of the two in FGCs. As already discussed, directly funding facilities energized FGCs
which contributed to realignment of executive arm and political arm roles and relationships.
1.5.3 Other Institutionalization for Sustainability Mechanisms
GOT and PS3 had a clear goal: by the end of the project, all responsible LGA and facility staff will use strengthened systems and management processes on a daily basis to perform their routine
work. This goal was successfully met as all GOT and PS3 strengthened systems are official
government systems, with staff across all levels of government taking ownership of and pride in
their use of the systems to improve their day-to-day work. As described throughout this report,
the investments in strengthened interoperable systems are producing efficiency gains vital to
sustaining improved management and extending coverage of services to Tanzanians.
In addition to GOT investment and ownership of strengthened systems, PS3 integrated capacity
building on functional knowledge and use of strengthened systems into undergraduate, graduate,
and continuing education:
PS3 helped incorporate resource tracking, including National Health Accounts
methodology, FFARS, and PlanRep into undergraduate and graduate courses. The
role of formal training institutions is central to the institutionalization of strengthened systems
and improved management, as ensuring staff have the required knowledge and skills is a basic
function of these institutions. Activities included dialogue, course development, formal
approval and incorporation into curriculum, orienting lecturers, and delivery of courses to
students. The courses are contained in different programs in different universities including:
UDSM graduate Economics program (started teaching); Mzumbe University undergraduate
and graduate Health Economics program (started teaching); and Muhimbili University of
Health and Allied Sciences graduate M&E program and Health Economics program (to be introduced in November 2020).
19
PS3 developed a strategy to integrate practical training on use of strengthened
national systems into LGTI curriculum, and to use Distance e-Learning (DeL)
hosted on PORALG servers as a sustainability mechanism. LGTI is one of the right
institutions to build capacity because it has the mandate under PORALG to conduct training
for LGA institutions and public workers. Efficiency gains and reducing the cost of training was
a major driver of the decision to develop DeL as a mechanism for LGA continuing education.
LGA councilor training was selected as the first DeL course in recognition of the importance
of informing new councilors about their roles to improve governance, and to reduce the high
cost of councilor training. PORALG, LGTI, Open University of Tanzania, and PS3 developed
the LGA Councilor DeL course, performed user testing, and refined the course to improve
the learning experience. A total of 211 LGA councilors from six LGAs (Bahi, Chemba, Gairo,
Iringa, Kilolo, Kilosa) were trained through LGTI’s DeL course with mentorship by PS3. See
Section 2.4.3 for more details. This approach built LGTI’s capacity in course facilitation, and
provided practical experience in preparation for country-wide training. The second DeL
course was new staff orientation. The GOT-approved new staff orientation manual was well-suited to DeL conversion, and its use to orient all new government hires has substantial cost-
saving potential. To test the DeL course, 71 new employees from seven LGAs in Mtwara
region entered the new course; out of 71 participants, 77.5% successfully completed the
course and were awarded certificates by LGTI.
2. SYSTEM FUNCTIONS FOR SERVICE DELIVERY
2.1 Information Systems
PS3 focused on both sector-wide and sector-
specific systems; addressed system infrastructure,
management, maintenance, and interoperability;
and enabled data access and use. Combined, this
increased the use of evidence for decision-making,
improved management processes, increased
accountability for managing services, and ultimately
maximized public sector service outputs,
outcomes, and impact. See Exhibit 4.
2.1.1 LGA Epicor System
Prior to PS3, LGAs used different versions of Epicor
(e.g. 9.0 or 10.1). Different disconnected systems
were used for revenue collection and expenditure
accounting, which fragmented financial management.
In addition, expenses were recorded in LGA-level
accounts (rather than booked directly to the service
provider for whom expenses were made), thus
undermining transparency. In July 2018, GOT
launched a strengthened LGA Epicor 10.2 accounting
Exhibit 4: Impact of Information System Interventions at the Facility Level
20
system. The system is one of the four pillars (with PlanRep, LGRCIS, and FFARS) of the LGA and
facility PFM system foundation. Together, these pillars increase transparency and strengthen the
basic financial management functions required to improve delivery of all LGA and facility-level
public services to citizens.
PORALG, RS, LGAs, MOFP, and
SoftTech worked with PS3 to support
the design, development, and testing of
the strengthened LGA Epicor accounting
system. A key activity was adding service
provider codes to LGA chart of accounts
to extend booking of expenses to the
facility level. This was a critical
contribution towards sustainability of
increased facility autonomy and accountability, ensuring facility-level expenses were incorporated
into the core country budget, finance, and accounting structure. Additional activities included:
reconfiguring Epicor 10.2 and shifting all LGAs to this standard version; and making Epicor interoperable with other LGA and facility PFM systems (e.g. PlanRep, LGRCIS, and FFARS). GOT
and PS3 technical teams deployed the strengthened Epicor system in all 185 LGAs, mentored
LGA staff on its use, fixed bugs, and refined the system. PORALG, MOFP, and Public Finance
Management Reform Program (PFMRP) V, and PS3 also added an asset management module to
improve year-end closure of LGA accounts, fully automate production of year-end financial
statements, and establish a foundation for better planning of capital investments and management
and maintenance of capital assets (critical for sustainable service delivery improvement). GOT
and PFMRP V with PS3 also configured the asset management module, conducted user acceptance
testing, and began deployment in all LGAs in the Dodoma, Kagera, Mara, and Mwanza regions
(GOT and PFMRP V will complete deployment in all regions/LGAs).
2.1.2 Local Government Revenue Collection Information System (LGRCIS)
LGAs use their own source revenue (e.g., local taxes, fees,
or licenses) for services, operations, and development,
supplementing their central budget funds. GOT requires
LGAs to use automated systems to collect taxpayer revenue
but transparent, efficient, and convenient collection of own
source revenue has been challenging. LGRCIS, a centralized
system housed at PORALG, is one of the approved tax
collection systems developed to optimize revenue collection
by reducing tax evasion and fraudulent practices. PORALG
and World Bank developed an LGRCIS mobile application for android-based smart phones. The
mobile application is cheaper than point-of-service machines, allowing LGAs to cover more
revenue collection points (approximately 16,000 mobile locations and point-of-service machines
countrywide), and make tax payments easier, quicker, and more transparent. In 2017, PS3
supported GOT to accelerate nationwide rollout of the LGRCIS mobile application. Activities
“EPICOR 10.2 will improve efficiency in accounting,
reporting and financial management. All the basic PFM
systems are now integrated and will be able to talk to
each other. In the past, LGAs used to view budgets in
one system and accounting in another system, making
it very difficult to show accountability in use of public
funds,” Accountant Busega District Council in Simiyu
“Our improvement is due to the
introduction of the LGRCIS on
one hand, and training of
revenue accountants on the use
and management of the system
by PS3 on other.” Njombe Town
Council Treasurer.
21
included mentoring or on-the-job training,
use of simple job aids, troubleshooting, and
further system refinements based on user
experiences. In the 93 LGAs directly
supported by PS3, tax revenue collected by
LGAs increased (by 3.7% in 2017, 16% in
2018, and 35% in 2019). LGAs invested
increases in LGA gross (total) revenue
collected, as well as increases in net revenue
due to efficiency gains (gross revenue minus
administrative costs of collection), in their
services, programs, operations, and
development. However, own source revenue
increase is a complex indicator with variation
across years due to multiple factors (e.g.,
changes in definition of LGA own source revenue, changes in types of taxes or fees, and inconsistency on when revenue is booked).
Nevertheless, there was a positive trend towards increased LGA own source revenue, and a
correlation between strengthening LGRCIS and increased revenue collection.
2.1.3 GOT Health Operations Management Information System (GoTHOMIS)
GoTHOMIS was developed to support clinicians and managers in their day-to-day tasks. The
system is used to schedule appointments, collect revenue, maintain patient histories, order
laboratory tests, prescribe drugs, and perform case management. GoTHOMIS introduced a new
way of managing clinical services, increasing efficiency, reducing errors, and improving the
accuracy, consistency, and timeliness of clinical and facility management information. In addition to improvements in general and financial management driven
by DFF and strengthened interoperable cross-sectoral PFM
systems (i.e., PlanRep and FFARS), GoTHOMIS strengthened
and linked specific aspects of health service delivery/ clinical
management.
PORALG and MOHCDGEC worked with PS3 and other
DPs to support GoTHOMIS Standard, the version capable of
managing most clinical services in all health facilities. PS3
supported GOT-organized dialogue to gather user
requirements and develop a roadmap for extending the
system to facilities, and subsequently supported its
deployment. A step-by-step approach was used to address
the substantial ICT infrastructure requirements. In addition,
cost-share between LGAs, health facilities, and PS3 meant it
was possible to extend local area networks, install
GoTHOMIS, and provide user training. In 2019, GoTHOMIS
A revenue collector (right) provides a receipt to a small vendor at the Mtwara main market using the mobile LGRCIS machine. (Credit: PS3)
“Before installation we had time-
consuming movement of patient
files and registrars searching
patient files manually in the
cabinet first before proceeding to
other departments to get
services, thus delaying health
services to clients. But after
installation of GoTHOMIS, the
system replaces movement of
manual client files and reduces
registry department tasks, and it
has also reduced bureaucracy
and patient queue.” –
Nanyamnba TC health worker
22
Standard was operating in approximately
10% of health facilities nationwide (457),
17% of district hospitals, 48% of health
centers, 30% of dispensaries, and 5% of
other types of health facilities. GOT plans
to further develop and refine the system
to address the complex nature of health
services, and over time, integrate vertical
programs, such as HIV/AIDS or
tuberculosis services.
PORALG and MOHCDGEC worked with
PS3, the GHSC project, and other DPs, to
make GoTHOMIS interoperable with
HMIS/DHIS2 (for statistical purposes), as
well as with eLMIS and NHIF. The systems
were made interoperable through two information mediators, the PORALG
Muungano Gateway and MOHCDGEC HIM. Interoperability allows facility managers to use the
same system to manage inventory of drugs (including ordering new stock), collect revenue, and
submit health insurance claims. GoTHOMIS Lite, a simplified mobile version of the program, was
designed for frontline primary healthcare services, particularly dispensaries. It can be downloaded
directly to a mobile phone for use, and its streamlined interface means it can be used in parallel
with the mobile version of FFARS. PORALG and PS3 developed and tested GoTHOMIS Lite.
Nationwide implementation (planned for 2020) will ensure that even the most remote providers
can generate and use the clinical and financial information they need to improve management of
frontline services.
2.1.4 Interoperability and Integrated Monitoring and Evaluation System (iMES)
PORALG worked with PS3 to design and implement the Muungano Gateway, an information
mediator that enables the exchange of data between multiple systems. PS3 also engaged in
dialogue and addressed interoperability issues between the PORALG Muungano Gateway and
MOHCDGEC HIM, and supported broad strategy development for linkages between the
Muungano Gateway, MOFP information mediator, and the eGA umbrella information mediator.
Development of the Muungano Gateway was a complex process. Activities included: research,
analysis, and dialogue about the nature of system interoperability; system architecture
development; configuration of the programming interface; continuous technical improvements
(e.g., notifications and system security); system
management; and refinement to align with underlying
system modifications.
Making national, LGA, and facility level cross-sectoral and
sector-specific systems interoperable improved basic
management functions. At the facility level, interoperable
systems enabled 24,229 health facilities and schools to
auto-populate budgets from PlanRep to FFARS.
Pharmacists from Mara Regional Hospital, Deogratius John and Ester Muna issuing drugs at the hospital pharmacy using GoTHOMIS. (Photo Stephano Amoni, Mara)
“Linking PlanRep, FFARS, LGRCIS,
and Epicor has enabled those of
us who supervise budget
implementation in our LGAs to
identify what is happening in other
systems.” Economist in Songea
MC Ruvuma
23
Interoperability between PlanRep, LGRCIS, Epicor, and FFARS changed work processes for LGA
officials—they could compare revenue and expenditure in one system and quickly obtain a clear
picture of their financial situation. The health sector benefited from interoperability between
PlanRep and HMIS/DHIS2 (critical for functioning of the revised CCHP guideline), WISN plus
POA and HMIS/DHIS2 (to prioritize staff distribution), and GoTHOMIS, HMIS/DHIS2, eLMIS and
NHIF (for claims management). Exhibit 5 summarizes interoperability between key systems,
including the relationships between PORALG and MOHCDGEC systems and information
mediators.
PORALG, eGA, and sector ministries also worked with PS3 to develop iMES, a cross-sectoral
web-based system built on the DHIS2 platform. Selected information from cross-sectoral and
sector-specific interoperable systems flowing through Muungano Gateway is exported and stored
in iMES, together with information from other systems hosted outside PORALG, including
systems flowing through the MOHCDGEC HIM. iMES began to improve efficiency in extraction
and collation of LGA data, and supported production of timely and relevant reports. One of the
core features of iMES is its public portal: www.imesportal.tamisemi.go.tz. PS3 helped configure
the public iMES portal, providing access to data approved by PORALG for public consumption using dashboards and charts.
Exhibit 5: System Interoperability through Muungano Gateway and Health
Information Mediator
24
2.1.5 Local Area Networks and Help Desk
Local area networks (LANs) are a precondition for
successful operation and routine use of strengthened GOT
and PS3 systems. GOT and PS3 strengthened LANs in all
13 regions and 93 LGAs (100% of targeted LGAs)
supported directly by PS3. Activities included: an IT
assessment in all LGAs; network extension design focused
on key management functions and sector departments
(e.g., planning, finance, HR, and health); procurement of
small equipment; support to LGAs to install the LANs;
mentoring LGA ICT officers on network use and
management; and advocacy for inclusion of LAN maintenance in LGA plans and budgets in
PlanRep. However, institutionalization requires national implementation of strengthened systems
(not piloting or fragmented deployment, which would undermine GOT ownership). PS3
therefore provided technical assistance to the Global Fund Resilient Systems Strengthened for
Health (RSSH) grant to justify and specify LANs in the 13 regions and 92 LGAs not supported by
PS3; the Global Fund subsequently approved, and equipment was procured by MOHCDGEC.
Throughout the period of PS3 implementation, system expert groups consisting of Tanzanian
national, regional, and LGA public workers and PS3 staff were the main mechanism for developing
and deploying strengthened national systems. To sustain user support, the PORALG DICT
worked with PS3 to establish a Help Desk. PS3 helped establish a management structure, train
staff and clarify roles and relationships. The Help Desk
supports seven systems (PlanRep, Epicor, LGRCIS, FFARS,
Government Mailing System, networks, and general ICT
questions or problems), with plans to extend to the
regional level and add support for more systems over time.
A customized web-based system is used to create tickets,
allowing technicians to enter, support, track, document,
and respond to RS, LGA, and facility user questions, issues,
and requests. The Help Desk sends a notification to users
after an action has been taken or a problem resolved;
generates daily reports on the status and number of tickets
that have been resolved or pending; and takes the lead in
collecting input from users about system issues or
upgrades, performing system refinements based on both
GOT mandates and user input.
2.2. Finance
DFF and its shift to output-based payment changed the way money was paid to health facilities
and schools, and triggered their transformation into entities performing the basic management
functions required to deliver outputs (i.e., produce a product or deliver a service). See Exhibit 6.
These cross-sectoral basic management functions include planning, budgeting, procurement,
accounting, HR management, and reporting. However, DFF will only yield its expected results if
Technician installs LAN in Magu LGA in Mwanza Region (Credit: PS3)
“We were required to travel out of
our Council to find reliable network
when we wanted to access Lawson
system. We sometimes had to work
in the middle of the night when the
network was not busy,” explains
Njombe Council’s HR Officer. With
the installation of LAN at the
Council, everything is now being
done at their offices: “It used to take
30 minutes to feed new staff
information into the system, the
process only takes three minutes
now which speeds up staff reporting
to their assigned stations.”
25
there are robust financial management
practices at the LGA and service provider
levels, and health facilities and schools are
ready to capitalize on financing reforms. GOT
and PS3 succeeded in both empowering
service delivery improvements and ensuring
good financial management by creating a new
PFM and sector service purchasing/payment
intersection, as shown in Exhibit 7. This
enabled both good financial controls and
“buying the right thing” to better match payment
to priority services, as well as increasing
efficiency and reducing waste. Creation of a new
intersection also enabled the health sector to
establish sequencing for movement towards a
SNHI and UHC.
2.1.1 Output-Based Payment and
Single National Health Insurance
(SNHI)
A GOT and PS3 priority was ensuring that
strengthened systems improved service delivery, particularly for underserved populations, by
improving the payment systems used to purchase health and education services. DFF and the shift
to output-based payment in the health sector increased efficiency by reducing fragmentation and
conflicting financial incentives, and realigned roles and relationships around greater facility
transparency, autonomy, and accountability. The first phase entailed introduction of a mixed
payment model consisting of core primary healthcare per capita payment for public HBF and
improved community health fund (iCHF) premiums, together with fee-for-service in an RBF
Exhibit 6: Impact of Finance Interventions at the
Facility Level
Exhibit 7: New Intersection of PFM and Sector Service Purchasing/Provider Payment
26
program to incentivize service
delivery improvements. The
primary healthcare per capita
payment formula included a base
rate (the facility fee) and three
adjusters—need (catchment
population), performance (service
use), and equity (distance).
GOT, HBF funders, other DP
projects, and PS3 supported the
shift to output-based payment
through primary healthcare per
capita payment for 5,459 health
centers and dispensaries in all 185
LGAs in Tanzania. PS3 helped
MOHCDGEC and PORALG to improve data quality for capitated rate payment adjusters and to calculate facility-level payments.
PS3 also strengthened the automated payment system and began the process of integrating it into
NHIF systems. In addition, PS3 supported dialogue and coordinated development of iCHF, and
helped harmonize HBF and iCHF payment systems to avoid conflicting incentives for payment to
primary healthcare providers. At the end of PS3, 98.5% of health facilities were paid through the
new or improved output-based payment systems.
RBF provides a powerful incentive for service delivery improvements. GOT and PS3 leveraged
RBF to trigger a variety of interventions, including DFF for health with its shift to output-based
payment, and extension of a health information system to the facility level (RBF requires facility-
specific data). PS3 supported MOHCDGEC, PO-RALG, and the World Bank to: improve the
institutional arrangements for RBF; implement a star rating system (e.g., facility accreditation for
entry into the RBF program); improve data quality and analysis; monitor invoicing and payment
processes; and support LGA mentoring and capacity building in Kagera, Kigoma, Mwanza and
Shinyanga regions. In addition, MOHCDGEC, MSD, NHIF, and the GHSC project worked with
PS3 to develop and implement an automated system to calculate MSD RBF indicators and
payments. RBF program challenges included MOFP operations and requirements that led to
delays in disbursing funds to facilities; PS3 mitigated these challenges with varying levels of success.
To initiate the second phase of strategic purchasing and DFF for health, MOHCDGEC/NHIF and
PS3 began to refine NHIF payment systems, harmonize information/claims management systems,
and prepare for SNHI purchasing. Activities included dialogue about the shift for hospital and
outpatient specialty payment from fee-for-service to a formula-based budget neutral payment
system. PS3 also helped develop detailed plans to establish a new hierarchy to classify hospital
cases for payment, conduct hospital cost accounting, calculate relative payment weights, and
improve claims management. In addition, PS3 supported dialogue about shifting domestic general
revenue funding for other charges or recurrent costs of patient care to output-based payment.
Major health financing reform in Tanzania will help ensure that every citizen has equal access to
health services through a SNHI with a standard Minimum Benefit Package entitlement. GOT
approval of the Health Financing Strategy and SNHI Law/Act was a lengthy process. PS3
A nurse attends to a mother and her daughter at Sirari Health Center in Tarime TC, which benefits from DHFF. (Photo: PS3)
27
supported MOHCDGEC to develop cabinet papers and respond to many rounds of questions
from the Intergovernmental Technical Commission. The main policy topics were fragmentation
and pooling, cost and investment, and institutional arrangements:
Stakeholder opinions varied on whether there should be one pool for the Minimum Benefit Package, or separate pools for civil servants and/or the formal sector, and for the
informal sector and the poor—ultimately GOT reaffirmed its intent to establish one
insurance pool to provide equal access to a standard package for all citizens, including the
poor and underserved.
Policy dialogue and an actuarial study focused on SNHI cost and resulted in understanding
that general revenue funds would be required but would need to increase over time.
Policy dialogue about institutional arrangements included the merger of SNHI and Worker’s Compensation Fund to reduce overlapping or fragmented social protection
programs.
Following a second actuarial study and gathering of stakeholder opinions, it is expected that final
SNHI policy decisions will be made, and the National Health Insurance Act developed, passed by
Parliament, and implemented. Although the SNHI policy dialogue process took time, it built
awareness across national ministries and increased ownership among stakeholders. During this
period, concurrent implementation of DFF for health and the shift to output-based payment and
cross-sectoral PFM systems established the foundation needed to manage SNHI operations. The
future looks bright for Tanzania to realize the full impact and benefits of DFF for health by
establishing the SNHI architecture, including the policy, legal, and institutional frameworks
required to increase general revenue for the poor, transfer and pool funds in NHIF, and define a
Minimum Benefit Package.
PS3 also supported the education sector to improve its output-based payment system. Education
was the first sector to implement DFF and the corresponding shift to output-based payment for
schools. This was achieved by introducing capitation payment in primary and secondary schools—
MOFP disburses funds directly to school bank accounts using a flat fee adjusted by the number
of enrolled students. Following implementation of a budget neutral formula-based system in the
health sector, PS3 worked with MOEST, PORALG, and the education Programme for Results
(P4R), to develop a payment formula for education (comparable to health) that adjusts for the
needs and characteristics of individual schools to increase equity and fairness in payment. MOEST
and PORALG approved and submitted the proposal to MOFP, together with a request for a
budget increase (due to education underfunding) and to protect schools from having their total
payments reduced due to any changes in the payment formula. At the time of writing, MOFP had
not yet approved the budget increase, although there did not appear to be any issues with
payment formula specification.
2.1.2 DFF Management
Following introduction of DFF for health in 2017, PO-RALG, RS, LGAs, health facilities,
MOHCDGEC, NHIF, MSD, the Health Services Support Project, HBF funders, the German
Agency for International Cooperation (GIZ), Providing for Health (P4H), the GHSC project, and
PS3 collaborated to train approximately 13,000 national, regional, LGA, and health facility staff on
how to use and manage their DFF funds. The massive cascade training increased awareness, built
capacity, and equipped facilities to spend their funds to improve service delivery. The training
28
included: determining the best mix of inputs to procure to deliver priority services; addressing
any procurement or other PFM barriers; and performing expenditure management functions. DFF
management training included facility planning, budgeting, procurement, and financial
management. The training also integrated iCHF national implementation and use of a prime
vendor system as an alternative supplier in response to MSD stock-outs. By the end of PS3, over
99% of health facilities were using FFARS to account for facility DFF expenditures, demonstrating
that they were following procedures.
PS3 also worked with PORALG,
MOHCDGEC, MSD, and the GHSC project
to strengthen and make FFARS, the MSD
Epicor-9 accounting system, and eLMIS
interoperable. Budget funds allocated by
MOFP to MSD were made visible in FFARS,
thus enabling facilities to plan their
procurement of medicines and other
supplies. In addition, facilities were able to procure drugs from MSD with the FFARS,
e-LMIS, and MSD Epicor systems supporting
the process. Furthermore, interoperability
will enable MSD to monitor stock-outs
across all facilities and therefore improve its
procurement planning.
GOT and PS3 also increased clarity and consistency in the rules governing how facilities could
spend their DFF funds. Different rules in different funding flows created confusion and
inefficiencies for facilities as they tried to manage consolidated funds. MOHCDGEC, PORALG,
and DPs worked with PS3 to review facility-level spending guidelines and to begin to harmonize
guidelines across revenue sources. This included improvements in the revised CCHP guideline
and subsequent PlanRep refinement (implemented on July 1, 2020). PS3 also worked with
PORALG and other DPs to draft a DFF Management Framework for health with a focus on
aligning roles and relationships for each function (receipt of funds, planning and budgeting,
procurement, internal controls, accounting and reporting, HR management, service delivery, and
M&E). This is scheduled for approval and implementation in late 2020/2021 and will solidify health
facility level management of DFF funds.
2.1.3 Service Outputs
PlanRep redesign responded to both the need for IT improvements and for financial reform—
system extension to the facility level was a key driver of increased management autonomy and
accountability, while addition of service outputs empowered facilities to plan and budget for
priority services. PS3 supported all levels of government and multiple sectors (including health,
education, and agriculture) to better define their service outputs in PlanRep as a pre-condition
for shifting from input- to output-based payment. Focal areas were nutrition, gender, and social
welfare—public sector services in these areas reflect the contribution of many sectors and impact
directly on underserved populations. Defining service outputs ultimately improved transparency
and ensured multi-sectoral service delivery was better targeted to priority needs.
Health training on use and management of DFF, iCHF, and prime
vendor system (Credit: PS3)
29
For example, inclusion of a PlanRep nutrition objective and 12 corresponding service outputs
improved multi-sectoral planning and budgeting for nutrition during the FY2019/20 cycle.
PORALG Nutrition Coordination Unit, MOHCDGEC, UNICEF, and other DPs worked with PS3
to conduct budget scrutiny workshops and orient RS/LGA staff responsible for implementing
nutrition plans and budgets. Nutrition funds and activities were previously hidden among multiple
line items and sector budgets, making it difficult to
identify what was planned and budgeted. By
aligning nutrition activities to service outputs, the
analysis unveiled a FY2019/20 budget of TZS 16.7
billion compared to the TZS 50 billion that was
previously estimated. A lower than expected
nutrition budget is not good news but increasing
transparency for actual nutrition plans and
budgets previously buried in other sector budgets
enables more realistic program implementation.
Alignment of activities to service outputs improved planning and budgeting for nutrition,
reduced budgeting errors, ensured better use of
existing resources, raised awareness of service
needs, and provided evidence to advocate for
increased funding for nutrition.
PS3 also helped GOT refine gender service output definitions and disaggregate resource
allocation by gender, enabling the LGA Community Development Departments (CDDs) to better
plan, budget, and implement gender activities. Four service outputs were defined to improve
gender integration and sensitivity: gender mainstreaming across sectors; women’s access to labor-
saving technologies; women’s participation in decision-making; and gender-based violence
services. PlanRep now enables analysis of LGA alignment to national priority gender policies.
Analysis of LGA budget allocations to gender-based violence service outputs showed a substantial
increase from 0.340 billion TZS in FY2018/19 to 3.3 billion TZS in FY2019/20.
2.1.4 Financial Reports and Resource Tracking
LGAs must submit a Council Financial Report (CFR), Council Development Report, and Medium-
Term Expenditure Framework (commonly known as the Council Budget) to the regional and
national levels. PORALG Directorate of Local Government Finance Department worked with
PS3 to initiate an assessment of CFRs and help strengthen intergovernmental fiscal transfers from
the national to LGA level. Many factors beyond the reach of PS3 determine the level of
intergovernmental fiscal transfers to LGAs, including fiscal situation, political will, and aspects of
the national budget formation process. However, the Directorate of Local Government Finance
Department and PS3 found that the existing Excel system and manual process of compiling or
aggregating individual LGA CFRs into national data and reports frequently resulted in data issues
or errors. PORALG therefore worked with PS3 to clean yearly CFR data and build capacity to
analyze LGA financial data. Demonstrated improvements in LGA financial management provided
the basis for a business case to MOFP to increase intergovernmental fiscal transfers for LGAs
and facility service delivery. CFR datasets were also used for PS3 M&E plan indicators, the mid-
term evaluation, and results assessment.
Minister of State in PORALG, Selemani Jafo, addressing a brainstorming session (sector ministries, DPs, and implementing partners) to refine and finalize social welfare services
30
In parallel, LGA and facility PFM systems (PlanRep, Epicor, FFARS, and LGRCIS) were
strengthened and made interoperable. PORALG recognized the corresponding opportunity to
generate reports automatically—strengthened interoperable systems enabled automatic and on-
time production of LGA CFRs, Council Development Reports, and the Medium-Term
Expenditure Framework. This increased efficiency, reduced administrative costs, improved data
quality, and increased access to more suitable data for analysis. Automated generation of LGA
financial reports also enabled better use of information for managing LGA finances, provided the
evidence needed to advocate to MOFP to increase intergovernmental fiscal transfers, and
established an environment in PORALG for improved data analysis capacity. PS3 monitored the
percentage of LGAs submitting complete reports on time (CFRs, Council Development Reports,
and Medium-Term Expenditure Framework)—the baseline was 43.8%, which rose to 100% in
Year 4 with the automatic generation of the reports.
Resource tracking can supplement accounting systems and reports to inform ongoing analysis,
policy dialogue, and system refinement. PS3 provided technical assistance to MOHCDGEC to
finalize National Health Accounts analysis and reporting for FY2013/14, FY2014/15, and
FY2015/16. For FY2016/17 and 2017/18, PS3 provided technical assistance to MOHCDGEC to train data collectors and analyze the data (data analysis was ongoing under MOHCDGEC’s
leadership at the time of writing of this report). To institutionalize the National Health Accounts
process, PS3 worked with WHO to train MOHCDGEC staff on using the Production Tool to
analyze data and produce reports. In addition, PS3 collaborated with WHO to orient civil society
and non-governmental organizations on the importance of National Health Accounts and its
production to gain wider stakeholder buy-in and enhance their production and use in the future.
2.3 Human Resources
HR management extends far beyond
allocating and distributing staff and payroll
administration into systematically
managing human talent to meet
organizational objectives. HR allocation
and distribution, staff orientation and
retention, and performance management
are critical in the context of fiscal
constraints and workforce shortfalls, as
good HR management for performance
and productivity can help offset shortages,
increase productivity, and ultimately impact on service delivery. As summarized
in Exhibit 8, PS3 focused on the public
sector’s ability to attract, develop, and
retain staff with the right skills and in the
right positions, ensuring that staff were
supported and motivated to perform well,
particularly in an environment of limited
financial and human resources.
Exhibit 8: Impact of HR Interventions at the Facility Level
31
2.1.5 New Staff Orientation
Regional and LGA officers, as well as new facility staff, reported challenges with orientation and
induction in terms of inappropriate timing, as well as inadequate resources, guidelines, training,
and materials. Such challenges can contribute to poor performance if staff are not fully aware of
their roles or conditions of employment, ultimately affecting service quality. Sector ministries may
orient staff on specific functions or service tasks, but a general orientation on HR topics and work
environment is important for the
positive entry and ultimate retention
of new staff. In July 2017, the
PORALG Minister launched
nationwide implementation of the
new staff orientation manual and
process for both sectoral and
administrative staff in all 26 regions
and 185 LGAs. The approved manual
was the culmination of an extensive
and participatory technical working
group process with representatives
from POPSMGG, PORALG, RS,
LGAs, Tanzania Public Service
College, LGTI, and PS3.
PS3 subsequently mentored LGAs to use the manual and customize their own process, and assign
responsibilities to orient new staff. PS3 supported GOT to institutionalize the process with
minimal external support by:
Establishing a “buddy” system at LGA, lower local government, and facility levels;
Increasing regional level oversight of new staff orientations;
Facilitating ongoing dialogue with POPSMGG resulting in inclusion of new staff orientation as a data element in the redesigned HCMIS; and
Developing and testing an LGTI DeL new staff orientation
course.
By the end of PS3, 55.4% of new staff received a job
orientation using the approved manual, a process that was
implemented and managed largely by LGAs. The percentage of
new staff receiving an orientation will increase over time with
deployment of the LGTI new staff or orientation DeL course
and monitoring through the redesigned HCMIS. An important
aspect of implementation was linking new staff orientation
with retention and performance management—see below.
New staff oriented in Kwimba DC (20 health staff, 10 teachers, four Accounts Assistants and three Village Executive Officers) Credit: PS3
“As new staff, I really appreciate
receiving orientation and a warm
welcome by heads of departments.
I was nervous to work in a new
environment but the orientation
gave me the courage and
confidence to perform my
responsibilities.” - new
Pharmaceutical Technician at
Mkomaindo Hospital in Masasi
Town Counil, Mtwara region.
32
2.1.6 Customized Retention Strategies
Tanzania previously had little success in implementing the National Pay and Incentive Policy due
to limited funding and reliance on top-down strategies, plans, and modalities. Extensive policy
dialogue with POPSMGG, the Public Service Remuneration Board, PORALG, RS, LGAs, and
sector ministries resulted in agreement to use a bottom-up approach of customized LGA
retention strategies. A technical working group of GOT and PS3 staff developed, tested, and
refined a package of tools to empower LGAs to develop their own retention strategies.
POPSMGG, the Public Service Remuneration Board,
PORALG, and joint RS and PS3 mentor teams, used the
package of materials to support PS3 Phase I LGAs to
develop customized LGA retention strategies. PS3
mentors supported LGAs to design their retention
packages focused on innovative approaches to retain
LGA staff based on the needs of their own staff and their
unique environment. PS3 mentors also helped LGAs
shepherd the packages through the required approval
processes. All 26 PS3 Phase I LGAs, as well as an
additional six LGAs in Dodoma, developed and approved
their own customized retention strategies. PS3
mentored LGAs to implement their customized
retention strategies, while also leveraging opportunities
availed by system strengthening efforts and reforms
(including DFF) to provide real incentives to help retain
staff. For example, LGAs incorporated customized
retention incentives in their PlanRep plans and budgets for FY2018/19 and FY2019/20. In
Nanyamba, 20 new science teachers received a cash incentive for reporting to the LGA; Masasi
gave 14 motorcycles to Ward Education Officers; Rorya disbursed cash prizes to the top 15 staff
performers; and Chunya, Kalambo and Kwimba built or rehabilitated staff houses.
Retention rates of recruited staff in the 26 PS3 Phase I LGAs increased from 65% in Year 3 to
99% in Year 4. “Retained” was defined as the number of newly recruited staff who reported to
service provider posts and stayed at their post for at least one year. While many factors impact
on staff retention, this substantial increase correlates with GOT and PS3 interventions.
Customized LGA retention strategies introduced a new
approach, facilitated collaboration across levels of
government, and empowered LGAs to realize investment
in staff retention. Development and implementation of
customized LGA retention strategies provided evidence
that, with support from DFF and improved planning and
budgeting, LGAs are able to incentivize their staff and
contribute to increased staff retention.
“Now DFF and PlanRep system
disburses all the funds directly to us
promptly, which has improved service
delivery and motivated staff to
continue to work in the health
center.” – Health facility in-charge.
Kalambo District Council is a new
LGA established in December 2012.
This year Kalambo’s Full Council
approved a retention plan for the
LGA to offer plots of surveyed land to
workers through soft loans, paying by
installments at a reasonable price. By
February 2020, government workers
had purchased 82 plots for a
reasonable price of 700 Tanzania
shillings per square meter (the going
rate is 1,000 shillings per square
meter). The payment plan allows
workers to pay in installments over
12 months.
33
2.1.7 Open Performance Review and Appraisal System (OPRAS)
GOT manages the performance of civil servants through OPRAS, a formal HR appraisal system
applicable to all public sector workers. However, reaching consensus on and prioritizing the many
issues with using OPRAS, as well as development of strategies and plans to address them, was
challenging in itself. Following a fact-finding mission and extensive policy dialogue, POPSMGG, the
Public Service Commission, PORALG, and PS3 planned a way forward that recognized the
problems associated with goal-setting based on the LGA Strategic Plan and/or Annual Plan. This
was particularly true for frontline staff (e.g., teachers, nurses) who found it confusing and
unrealistic to extract OPRAS goals from broad strategic plans while also incorporating sector
standards and/or regulations (e.g., school curriculum, clinical guidelines).
POPSMGG, PORALG, and the Teacher’s
Service Commission worked with PS3 to
change the basis of OPRAS goals for teachers.
Instead of using LGA strategic plans, the new
OPRAS goals form/template was based on job
descriptions and competencies with standard
objectives and targets. PS3 helped GOT
implement the new teacher goals nationwide
by conducting regional workshops to
disseminate the simpler and more relevant
standard OPRAS template to RS and LGA
education officials in all 185 LGAs. The LGAs
then cascaded the training to all heads and
teachers in each school. GOT and PS3
mentoring and monitoring visits showed on
average 92% of teachers in schools completed
OPRAS forms using the new template.
The inefficient and costly manual system and process was also problematic; OPRAS was
inconvenient and burdensome for front-line service delivery workers in particular, and was
applied unevenly across the public sector. POPSMGG and PS3 therefore developed e-OPRAS to
automate performance management, and made it interoperable with the redesigned HCMIS (the
centralized HR management system used largely for payroll for all public servants). The
performance management module was a key focus; this will facilitate electronic record-keeping
of annual appraisals and support evidence-based decisions related to HR (e.g., for promotions,
rewards, discipline, and staff development). POPSMGG
plans to deploy the redesigned HCMIS and e-OPRAS
nationwide. Clear goals and a more efficient and
convenient appraisal process will enable staff to work
more effectively towards achieving their goals, produce
a better performance management process that
promotes individual accountability, and improve
transparency and communication between supervisors
and employees.
PS3 mentoring teachers on OPRAS during a visit in Bahi LGA, Dodoma Region. (Credit: PS3)
“Our previous filing system was not
efficient, and resulted in loss of
employee information. This caused
chaos when an employee claimed
benefits for either sickness, transfers, or
retirement.” -Tarime Town Council
District Executive Director
34
2.1.8 Personnel Records Personnel records management was very
inefficient and impacted negatively both staff
morale and service delivery. LGA assessments and
dialogue showed that substantial time was lost
searching for records, together with considerable
frustration and demotivation of public workers at
their inability to access their records, realize
allowances and benefits, and perform their daily life
activities (e.g., verify employment to obtain loans).
Poor records management also undermined
transparency and accountability as LGAs and their
staff lacked access to the information needed about
personnel management, guidelines, or programs they
were responsible for delivering.
GOT and PS3 developed and implemented an
incremental, bottom-up approach to strengthen
personnel records. The strategy was based on the
premise that cleaning up manual systems was a pre-
condition to automation, avoiding “garbage-in,
garbage out”, while also increasing LGA ownership
and pride in management improvements. PORALG,
the President’s Office Records and Archive
Management Department, and LGAs worked with
PS3 to decongest and better organize records in 30 LGAs (26 Phase I LGAs and four Phase II
LGAs selected by GOT). PS3 conducted on-the-job training and mentoring for LGA council
management teams, HR officers, and records personnel. LGA ownership of the process was
immediate. In addition, the process contributed to rapid improvements in HR/archive staff
motivation and generated substantial efficiency gains. In four LGAs studied, the time spent
searching for personnel records reduced by 47% compared to before the intervention. In addition,
having systematic personnel record archives built facility staff confidence that their records were
safe and well-maintained at the LGA level, enabled timely
resolution of HR matters, and improved management of
appraisal, transfer, leave, and other HR decisions.
Bottom-up LGA records and archive improvement also set the
stage for other activities. Specifically, GOT and PS3 leveraged
synergies between HR interventions by linking better
distribution of new health workers with new staff orientations,
and by opening personnel records or master files for all new
staff—something that had never been done before. Redesign of
HCMIS encompassed a broader approach to HR management
through its extension to the service provider level. This meant
that the location of all public workers was visible in GOT
systems, and incorporated employee actions, benefits, and
Records keeping staff in Ruangwa district, Lindi region decongest files in the Records Keeping Unit as part of PS3 intervention for personnel records improvement. (Photo: PS3)
Status of closed files in one of the LGAs awaiting sorting (Photo: PS3)
The e-Office system helped
GOT achieve substantial
efficiency gains:
“Normally it took us more
than two hours for file transfer
within Teacher’s Service
Commission. We now transfer
files in only five minutes. We
reduced costs and improved
record keeping, safety of
information and monitoring.” -
Teacher’s Service Commission
ICT Department Head.
35
career development (e.g., orientation, appraisals, promotions, transfers, leave, and continuing
education).
The GOT embraced e-Government, for example, by using the e-Office system. The Teacher’s
Service Commission was established in 2015 and is expected to transform teacher service
management, including maintaining personnel records for all teachers employed in the public
service. As a new institution, it was an ideal test case for extension of automated correspondence
and personnel records. PORALG, eGA, Teacher’s Service Commission, and PS3 introduced the
e-Office system. This automates the process of storing personnel records and receiving and
dispatching files and letters within and outside government institutions, replacing the current
manual practices or use of unsecure e-mails, thus increasing efficiencies and helping sustain
improvements.
2.4 Governance and Citizen Engagement
Tanzania has in place a range of LGA structures and platforms designed to improve governance
and encourage citizen engagement, including LGA Council, standing committees, WDCs, village
committees/mtaa, and FGCs. Exhibit 9 summarizes the impact of GOT and PS3 interventions on
governance and citizen engagement at the facility level. By giving facilities greater autonomy
through extended access to strengthened systems and DFF, facilities were better positioned to
engage communities and consequently realign services/outputs according to their needs, in turn
giving LGAs the time and space to fulfill their oversight role. By introducing DFF, committee
members had a meaningful function
because there were tangible resources
they needed to plan, budget, and provide
oversight for, while communities were
able to see resources flowing into their
communities and were therefore
motivated to provide feedback about how
those resources were used. In parallel to
performing their citizen engagement
responsibilities, FGCs began to perform
other governance functions, including
process (e.g., holding regular meetings)
and oversight (e.g., separation of functions
to strengthen PFM and increase
transparency by reviewing plans and budgets
and signing-off procurements and receipt of goods). As described below, strengthening
LGA systems or processes (e.g., websites,
complaints management, councilor training,
committee functioning, and financial
management) were critical to both
improving LGA governance and the
emergence of more active facility
governance through invigorated FGCs.
Exhibit 9: Impact of Governance and Citizen Engagement
at the Facility Level
36
2.1.1 Websites
A key GOT priority is providing citizens with up-to-date and
relevant information: open local government promotes
transparency, accountability, and oversight; empowers
citizens; strengthens intergovernmental systems; and leads to
more responsive LGAs and facilities. Websites in particular
provide opportunities to increase transparency and
information-sharing externally with citizens, and improve
efficiency, communication, and management across levels of
government. Joint GOT and PS3 design, development,
deployment, and training resulted in installation of websites in 26 RS and 185 LGAs with a national
launch held in March 2017. GOT cost-shared the deployment, training, and launch of websites in
the remaining 13 non-PS3 regions (92 LGAs). PORALG, eGA, and PS3 developed a Government
Website Framework, Content Guidelines, and an Orientation Manual. The framework includes a
standard template for all RS/LGAs to build their websites with a user-friendly interface that
enables customization and maintenance with little technical expertise.
GOT and PS3 developed a strategy and mentored LGA leadership, information officers, and ICT
officers to manage the process of uploading documents and ensuring the information shared with
citizens remained relevant and up-to-date. The Content Guidelines and Orientation Manual were
used to help information and ICT officers across the country abide by formal and consistent
standards for website management. GOT, including PORALG and the Ministry of Information,
are both directing and empowering RS and LGAs
to use websites to share information with citizens.
Dialogue with LGA councilors, committee
members, and staff revealed that most stakeholders, including citizens, would use LGA
websites more if they were accessible through
mobile (smart) phones. PORALG, Open
University of Tanzania, and PS3 responded by
developing, testing, and operationalizing a mobile
application. The website mobile application and
its corresponding user manual became available
early in 2020 and is expected to improve website
use, especially in areas with poor internet access.
The websites house government reports, budgets, and official forms, and provide a platform for
citizens to share feedback or complaints directly with LGAs. Out of 93 targeted LGAs, 83.9%
were sharing information with citizens by uploading data/information onto their website. This
indicator measured whether LGAs were sharing budgets and strategic plans, demonstrating
increased transparency and potential for social accountability. PS3 monitoring and analysis of
websites also showed the following:
LGAs were motivated to share information—in Year 4, approximately 75% of RS/LGAs
updated their website within 40 days.
Minister of State in PORALG, Hon. George SImbachawene, presses a key to signify launch of new Regional and LGA websites in the country.
“Before establishment of our LGA
website, we used to pay a lot for
newspaper adverts to reach a wide
audience for tenders, jobs, press
releases. Since the website, our
Council has saved more than fice
million TZS.” Kigoma Municipal
Council HR Officer, Bennet.
37
Websites were used increasingly by citizens to access information—one year after websites
were introduced, an average of 2,100 people viewed each LGA website, doubling to 5,225 by
April 2019.
Websites helped realize cost savings and efficiency gains—almost a third of LGAs uploaded forms for
public workers, allowing staff to spend their time at
facilities delivering services instead of traveling to
collect and complete forms.
The business community benefited from the
introduction of websites—by 2019, 29% of LGAs had
posted business license application forms on their websites, and the private sector increasingly accessed
forms via the websites without incurring travel costs.
2.1.2 Complaints Management
GOT receiving and acting on feedback is key to citizen
engagement, promoting more responsive systems, and
improving service delivery. Complaints management is fundamental to citizen engagement; the
process ranges from how the complaint is received to how it is referred and managed, providing
feedback to the complainant, and finally documenting it in the complaints system or register.
Strengthening complaints management was a high priority for both POPSMGG and PORALG,
reflected in repeated requests for PS3 support. PS3 conducted a complaints management study, which demonstrated that citizen feedback mechanisms were not working at the LGA level and
needed to be extended to the service delivery level.
POPSMGG and PORALG worked with PS3 to develop and implement mechanisms for
strengthening and extending citizen feedback and complaints management to the service delivery
level in four LGAs (Kishapu, Shinyanga; Kigoma-Ujiji, Kigoma; Mtwara-Mikindani, Mtwara; and
Bahi, Dodoma). During the first phase of implementation, the focus was improving the
responsiveness of LGA officials, staff, and service providers to citizen needs and adding a gender
perspective to the existing complaints system. Interrelated activities included: sensitizing RS and
LGA leadership; introducing POPSMGG guidelines; identifying and mentoring complaint handling
officers on the use of complaint registers;
developing reports for management and
council committees; and publishing
citizen rights and client service charters
in health facilities and schools.
In parallel, taking a bottom-up approach to
improving complaints management,
PORALG, LGAs, and PS3 mentored 26
Phase I LGAs to strengthen complaints
management and improve LGA
committee performance. Contributing
factors to improvement included a A councilor in Mtwara Mikindani MC advocates to his ward citizens on use of Complaints Offices (Photo PS3)
“The significance of this launch not
only lies in building efficiency,
transparency, and public trust. It also
lies in the importance of delegating
authority and decision-making power
to LGAs. The new website framework
is a critical step forward in this
direction. It shows a commitment to
decentralization, with an emphasis on
allowing regional and local government
to use information to respond to
citizen needs/” –
USAID/Tanzania Deputy Mission
Director, Timothy Donnay
38
substantial increase in the availability of complaints management guidelines. The commitment of
LGAs was demonstrated by appointing complaints handling officers, establishing complaints
management offices/desks, opening complaints registers and recording complaints, submitting
reports, and informing citizens about the existence of the service. The percentage of LGAs with
a complaints management desk/office increased from 34.6% to 73.1%, the percentage of LGAs
with complaints management registers available to citizens increased from 34.6% to 76.9%, and
the percentage of LGAs with a functioning complaint mechanism rose from a baseline of 46.2%
to 87.1%. POPSMGG was impressed with the results and wanted to disseminate the experience
to citizens nationwide. POPSMGG and PS3 therefore developed and aired television programs
and video clips in April 2020 to inform citizens about the complaints management system and to
advocate for its use. However more needs to be done to ensure the expansion and sustainability
of this approach.
2.1.3 LGA Councilor Training
LGA Councilors are key governance actors who can
exercise political power to manage the nation’s economic
and social resources for development at the local level.
During Year 1-2, PS3 governance activities started with
training 2,949 councilors from 93 LGAs at the request of
PORALG. The training increased councilor capacity to
perform their roles, serve as the entry point for all 93
LGAs, and pave the way for other LGA level
interventions (e.g., to increase citizen engagement and
strengthen committee functioning). The training also
fostered a better relationship and understanding between
the political and executive arms at the district council, ward, and village levels. By the end of the training, LGA
councilors were empowered to perform their roles, and
support the structures, systems, and processes designed
to promote better service delivery to citizens. In addition,
LGA councilors were empowered to act as a voice for
citizens with the government, thus increasing citizen
participation in development, and accountability of
government and citizens to one another.
The training included dialogue, development, and
dissemination of a booklet containing generic councilor
action plans, and an inventory of responsibilities and
activities that councilors could use to define, plan, and
manage their duties. This generic action plan was
approved by PORALG on May 4, 2017. Its use enabled
councilors to better perform their roles and document
their results and contributions to improving public sector
service delivery.
“Through the application of knowledge I
received during the training, things now
operate smoothly and much easier than
the early days when I started being a
Councilor. Most of all I have learnt the
importance of being transparent to
citizens and engaging them in decision
making.” Councilor Mohamed
Ngoromole, Songwa Ward from
Kishapu, Shinyanga.
Councilors learned there are clear
procedures for appointing members of
the Council Finance Committee and
that these were not followed during
the appointment of the committee:
“Using our acquired knowledge, we
successfully re-elected new Finance
Committee members.” Councilor
Gombo Doto Kamuli, from Ipagala
Ward, Dodoma.
“Through knowledge gained at the
training, I have been able to sensitize
citizens to enhance their participation in
developmental activities. We exercised
citizen engagement in the education
sector, and we now understand that it is
one of the major strategies to improve
access to quality education.” Councilor
Ihunyo Issa Kazi, from Kukirango ward,
Butiama, Mara.
39
2.1.4 Strengthening Committee Functioning
LGA committees are critical for citizen engagement and community involvement, and play a key
role in planning, financing, governance, and oversight of service delivery. Members are often
volunteers and therefore capacity building and increasing their motivation is vital to committee
functionality. Substantial dialogue was held about the status of LGA committees during LGA
councilor training (see above), including challenges and recommendations to improve their
performance. Bottlenecks identified during this dialogue included: council standing orders
diverging from the respective principle legislations (e.g., Public Procurement Act); outdated or
unavailable bylaws to support committees in executing their mandated functions; lack of
comprehensive guidelines for committees; lower local government and facility
committees/boards with limited knowledge of their roles and functions; shortage of reference
materials; and no system for monitoring committee performance.
PS3 helped strengthen committees in the 26 Phase I LGAs at the LGA, ward, village/mtaa and
facility level. In order to strengthen LGA standing committees and WDCs, PS3 developed and
deployed a benchmarking tool. This was used to identify gaps and informed mentoring of LGA
committees and committee clerks (who have a major role in supporting committees) to address
those gaps. PS3 helped LGAs strengthen the basic processes and functioning of committees by,
for example, ensuring committees were properly constituted, met according to approved
schedules, and executed their mandate according to existing guidelines, standing orders, and
bylaws. In addition, PS3 also ensured LGAs uploaded relevant information to RS/LGA websites
so that committees could access the information they needed. Benchmarking scores showed an
increase of 79% in committee functioning. Benchmarking results were used to advise LGA council
management teams to improve both the process and content aspects of committee functioning,
including links to strengthened systems (PlanRep, LGRCIS, Epicor, and FFARS).
Mentoring, benchmarking, and ongoing dialogue about documents for committee functioning (e.g., standing orders, bylaws, and guidelines) led to the observation that committee minutes were
inadequate at lower local government and facility levels; a simple standardized template was
required to record meeting minutes. PORALG and PS3 began development of a web-based
standard committee minute writing template. Uploading committee minutes to LGA websites will
increase transparency and accountability, and can also help incorporate approved community
input into plans and budgets.
2.1.5 LGA Financial Management and Accounting
PORALG and MOFP worked with PS3 to reduce the number of qualified audit opinions by
building the capacity of RS and LGA accountants and internal auditors. Interventions focused on
improving accounting and reporting in alignment with International Public Sector Accounting
Standards, and strengthening procedures for yearly closure of books and final accounts
preparation. During capacity building, inconsistencies were identified within LGA finance
templates. PORALG subsequently issued a circular (following dialogue with the Accountant
General) to revise LGA financial templates in alignment with International Public Sector
Accounting Standards, thus reducing the potential for LGAs to receive qualified opinions from
the Controller and Auditor General report. The percentage of targeted LGAs with clean audit
reports increased from a baseline of 25% (this was artificially low due to a land valuation issue,
which was subsequently resolved) to 96.8%.
40
The MOFP Internal Auditor General requested PS3 to help strengthen internal auditing by
introducing an automated system. The Auditor General selected the Teammate system, and PS3
supported Phase I implementation in nine LGAs in Morogoro region. Activities included:
customizing Teammate to suit the Tanzanian environment; procuring licenses and computers;
training for internal auditors; and mentoring to implement and refine processes. During
implementation, issues were identified with the high cost of Teammate licenses and its
configuration as a “standalone system”—it was difficult to manage, aggregate, and analyze data
for all LGAs. MOFP and PORALG therefore concluded that a web-based system on a centralized
server would be more efficient and effective, and could be made interoperable with other financial
management systems.
The MOFP Internal Auditor General, PORALG DICT, and Directorate of Inspectorate and
Financial Tracking and Department, PFMRP V, and PS3 developed and tested GIAMIS. The system
performs internal audit processes, thus strengthening LGA financial management, while also
solidifying the autonomy and accountability of facilities (they are included as an entity in the
system). The MOFP Internal Auditor General and PORALG agreed on roles and relationships,
including increased involvement of the Directorate of Inspectorate and Financial Tracking as the business process owner of internal LGA audits. The system was subsequently approved by MOFP,
with PFMRP V funds allocated for its deployment.
3. COLLABORATIONS
PS3 collaborated to its comparative advantages with USAID activities and other DP projects. In
addition, Regional/LGA operations collaborated with DP projects and leveraged funds for systems
strengthening to improve service delivery. PS3 collaborations are described in Exhibit 10.
Exhibit 10: PS3 Collaborations with USAID Activities and DP Projects
PS3 Collaborations with USAID Activities and Other Development Partner (DP) Projects
Partner(s) Collaboration Focus and Result
USAID Activities
Iringa Hub Participate in meetings and implement PS3 activities in the context of Iringa Hub plans
Touch Foundation WISN plus POA development, implementation, and integration into GOT systems
GHSC and other health
information system
projects
Develop and test interoperability between Muungano Gateway and HIM, MSD Epicor
and FFARS, and GOTHOMIS, HMIS/DHIS2, eLMIS, and NHIF claims management
Boresha Afya, other
USAID and CDC
service projects
Implement joint collaboration plan with emphasis on links to DFF, PlanRep, FFARS,
Epicor, health systems, other management systems, and region/LGA coordination
CHSSP and Kizazi Kipya Community Health and Social Welfare Systems (CHSSP). Social welfare service
outputs, and coordination of community workers
Health Policy Plus Dialogue on Inter-ministerial Technical Commission response to Health Financing
Strategy and SNHI
Governance Activities Participating in governance “Integration Baraza” meetings and activities
Lishe Endelevu Activity Nutrition coordination
Education Activity Coordination on empowering school governing boards
41
Agriculture Activities
Agriculture Sector Development Program-2: service outputs and public-private
dialogue with AfricaLead, Agriculture Sector Policy and Institutional Reform
Strengthening, Enabling Growth through Investment and Enterprise
Other Activities Meetings upon request, and work to identify potential collaborations
DP Projects
World Bank, Swiss, GIZ,
Danida, other HBF DPs
DFF HBF and its primary healthcare capitated rate payment system, DFF management
and facility procurement of inputs, FFARS and facility financial management
DFID, Norway, World
Bank, European Union,
other PFM DPs
Ongoing meetings and PFMRP V collaboration on Epicor including asset management,
GIAMIS, PlanRep, LGRCIS, FFARS, and other PFM systems. Collaborate with UK
Department for International Development (DFID) technical assistance at region level
UNICEF Strong links on PlanRep implementation, revising CCHP guideline, DFF, PFM, health
information systems and nutrition
World Bank RBF and dialogue on Public Service Management project (HR)
WHO, P4H, all health
financing DPs
SNHI policy dialogue, DFF, PFM, National Health Accounts. Supported Providing for
Health (P4H) in their health financing coordination role.
SDC/HPSS, GIZ, KfW
(German Development
Bank), P4H
iCHF implementation and agreement on harmonizing iCHF payment and information
systems with other DFF funds flow particularly HBF. Strong links with Swiss
Development Agency (SDC) Health Promotion and Systems Strengthening (HPSS)
Global Fund RSSH Development of Global Fund RSSH grant and extend LANs to non-PS3 region
OGAC/PEPFAR, Global
Fund, Gates Foundation Initial meeting on costing HIV/AIDS services and integration into primary healthcare
GIZ, Open Government
Partnership
Collaboration on sharing information with citizens, complaints management, and other
governance activities
Education projects
Education capitation grant payment formula and teacher allocation and distribution
with Education Program for Results. Link at region/LGA level with Sida Literacy and
Numeracy Education Support and DFID Education Quality Improvement Programme
4. OPERATIONS RESEARCH AND M&E
4.1 Operations Research
The PS3 operations research (OR) component evolved every year in parallel with the sequencing
and dynamics of program implementation. In the first year, OR focused on dialogue with LGA
level stakeholders through PS3 regional launches and LGA councilor training in order to gather
opinions and identify problems and potential solutions based on LGA realities. In Year 2, rapid
assessments were used to identify and investigate problems further, gathering user input with
sufficient specificity to enable productive dialogue with GOT. This was followed by concrete
design and development of strengthened systems and interventions. In Years 3-5, as strengthened
systems were deployed, OR was used during the early phases of implementation to detect or
ascertain questions where further study or analysis could help refine implementation or illuminate
specific challenges. The constant throughout was commitment to linking OR studies closely and
practically with GOT and PS3 implementation of strengthened systems to increase equity,
efficiency, transparency, and improvements in management and service delivery.
At USAID’s request, D4D and PS3 collaborated to analyze and further document PS3 results.
Focus areas included: quantifying cost savings and efficiency gains; revenue and expenditure trends
since introduction of PlanRep, FFARS, LGRCIS, and GoTHOMIS; and factors affecting system use
and sustainability. PS3 coordinated with GOT (for approval and participation), managed the
42
process, served as experts for details on systems and data, supported data extraction, and
performed preliminary analyses (e.g., PlanRep-related time and cost savings, LGRCIS and
GoTHOMIS revenue, and FFARS revenue and expenditure patterns). The analysis was still in
progress at the time of the writing.
The main PS3 OR product was a detailed qualitative analysis of the dynamics of change in health
facility and school management and governance in the context of DFF and extension of systems
(i.e., PlanRep and FFARS) to the facility level. The study focused on realignment of roles and
relationships between facility in-charges, facility staff, FGCs, and LGA officials in the context of
reforms and strengthened systems. The study was conducted in nine LGAs at 72 health facilities
(dispensaries and health centers) and schools (primary and secondary). A total of 708
respondents participated in 80 individual in-depth interviews and 162 focus group discussions
(242 individual and group interviews in total). Facility in-charges, facility staff, FGCs members,
district executive directors, LGA heads of departments, and LGA councilors generated 6,372
responses in the individual interviews and focus group discussions. Analysis and respondent
quotes are included throughout this final report. The study findings showed that respondents
were aware of DFF, PlanRep, and FFARS. The overall perception of health and school in-charges, staff, and FGCs was that DFF and extending systems to the facility level improved their ability to
manage and deliver public health and education services to their citizens and communities. These
views were largely echoed by LGA officers and councilors.
PS3 incorporated gender considerations into all interventions to realize delivery of services and
benefits to previously underserved groups, including women. Lessons drawn from international
experience suggest that gender equity in public expenditure can be furthered by making national
planning and payment systems more output-based to better match payment to priority services.
This is especially the case when policies, priority services, and benefits are gender sensitive—as
they are in Tanzania. In other words, supporting GOT
to strengthen systems to improve service delivery is
inherently gender transformative. The primary gender
activity was therefore better definition of public service
outputs and incorporation into payment adjustors (see
Section 2.2, Finance).
In addition, a Gender Assessment and dialogue with
MOHCDGEC and PO-RALG led to strengthening Phase
I LGA CDDs. LGA CDDs are responsible for leading
and coordinating gender and youth activities but receive
the least funding. PS3 developed a gender checklist,
which was used to help Phase I LGA CDDs improve
multi-sectoral gender planning and coordinate gender
mainstreaming across all LGA public sectors. In addition,
PS3 sensitized LGAs on using the gender checklist in
planning and budgeting in the context of the Gender Responsive Planning and Budgeting Initiative
supported by UN Women. PS3 also added a gender mainstreaming perspective to a variety of
PS3 Gender Advisor, Flora Kessy, runs an internal gender training for PS3 staff during the Review Meeting in February.
43
systems and interventions (e.g., LGA Councilor Training, committee benchmarking tool, and
complaints management system).
Other PS3 OR Studies included: an HR Assessment encompassing management and use of social
welfare officers especially at lower local government levels; Complaints Management study
recommending extension of complaints systems from LGA level to service provider level; and
Special Seats Legislation study exploring the role of Special Seat Councilors in their wards and
LGA Councils, and specifically their exclusion from leadership of standing committees. Other OR
topics that contributed to provision of technical assistance to GOT included: intergovernmental
fiscal transfers and improvement in LGA financial reports; increasing efficiency in LGA revenue
collection; and LGA use of websites. In addition, continuous exploration and analysis supported
refinement in GOT and PS3 implementation of strengthened systems to improve management
and service delivery.
4.2 M&E
The PS3 results framework is contained in Exhibit 11. Consistent with the PS3 implementation
strategy, this results framework portrays a direct link between systems strengthening and service
delivery improvements. It prioritizes the policy objectives of efficiency (better use of existing
resources), and responsiveness of public services to citizen needs.
Exhibit 11: PS3 Results Framework
PS3’s primary M&E task was to track progress on approved M&E Plan indicators for refinement
of program interventions and USAID contract reporting. PS3 used an Excel-based M&E system
for data collection, entry, analysis, and reporting. The system consisted of: 93 LGA indicator data
collection and entry worksheets; linked worksheets compiling all indicator data; and a reporting
worksheet, including comparison of target and indicator values. Most PS3 data was obtained from
GOT systems and collected on an annual basis, matching the GOT fiscal year ending June 30th.
The annual M&E indicator process included: refinement of the M&E system and process based on
44
the prior years’ experiences; preparation of the M&E system for the current year; and data
collection, entry, quality assurance, analysis, and reporting.
PS3 worked with D4D to complete external data quality assurance for three PS3 indicators for
reporting to USAID’s Implementing Partners Reporting System (IPRS). The three indicators
measured LGA clean audit reports, own source revenue, and citizen feedback. PS3 also reported
results on assigned PEPFAR indicators and additional nutrition indicators. All PS3 indicators and
yearly results are contained in Annex 1.
PS3 conducted other M&E tasks including: providing input to external evaluation and data quality
assurance as requested by USAID; feeding back monitoring information and building the capacity
of LGAs in M&E; and supporting technical component activities. PS3 supported GOT to
strengthen M&E, especially at LGA level, and institutionalize systems strengthening for
sustainability. The PS3 M&E team and regional program managers shared indicator results with
respective regions/LGAs. Using an informal bottom-up process, PS3 used LGA commitment and
interest in peer-to peer discussions on indicator results to continue to improve management and
service delivery. The involvement of LGA staff in data collection proved very effective in ensuring
LGA ownership of indicator results.
PS3 also provided M&E technical assistance in gender and nutrition. PS3 engaged in dialogue to
create demand within LGAs to support compliance with national gender strategy requirements
for reporting gender disaggregated data. This increased the potential to better define information
needs and use PlanRep to improve data for decision-making, planning, implementation of
activities, and tracking progress in advancing development objectives through gender
mainstreaming. PS3 also provided technical assistance to PORALG Nutrition Coordination Unit
to automate compact indicator data collection to improve efficiency in extraction and collation
of LGA data, with orientation of regional and district nutrition officers. PORALG Nutrition
Coordination Unit, DPs, and PS3 began to automate data collection for compact indicators by
integration into multi-sectoral nutrition information system (MNIS) linked to iMES. Previously,
nutrition officers manually extracted compact indicator data for all 185 LGAs, which was a tedious
and time consuming process.
5. COMMUNICATIONS
PS3 communications and knowledge management functions consisted of:
Ensuring timely submission of all contract deliverables;
Proactively managing GOT and PS3 correspondence;
Supporting quick and effective communication within PS3 (including use of the “Jamvi” internal platform), to share experiences, address challenges, and build on lessons learned;
Technical archiving;
Providing technical assistance to GOT on selected communications interventions; and
Supporting development of the joint PORALG and USAID/PS3 newsletter.
The vast majority of PS3 technical products were co-branded GOT and USAID/PS3, including
materials that comprised GOT systems, processes, regulations and guidance, or that were used
to implement GOT and PS3 interventions. A list of contractual deliverables submitted to USAID
and uploaded to the Development Experience Clearinghouse (DEC) is included in Annex 2. The
45
PS3 communications team supported all GOT and PS3
interventions requiring communication expertise, including
photographing activities. The team played a major role in
supporting PORALG to develop the Government Website
Framework (including the guidelines and operating manual);
websites were designed to share information with citizens
and improve GOT internal communication and
management. PORALG and PS3 also developed PlanRep,
FFARS and Epicor tutorials. The video-based tutorials were
designed to enable use of strengthened systems with a
step-by-step process on how regional, LGA, and facility
officers should access and use the systems. The tutorials
also provide a reference when users encounter system-
related challenges, and complement and enhance ongoing
PORALG and PS3 mentoring, as well as user support
available through PORALG’s Central Help Desk. The PS3 communications team also supported POPSMGG and the
governance team to develop and air TV programs and clips about the new complaints
management system, which POPSMGG aired to increase population awareness and promote the
system.
Joint Quarterly Newsletter
PORALG and PS3 worked together
to produce a joint newsletter,
Mifumo Yetu (“Our Systems”).
PORALG DICT, PORALG
Communications Unit, and PS3
successfully produced 12
newsletters (see Exhibit 12). The
newsletter describes the systems,
encourages their use, and is designed
to increase understanding among
readers (especially public workers
and citizens) about how services are
improved through systems
strengthening. Newsletter topics
include: 1) national launch of
RS/LGA websites; 2) FFARS; 3)
strengthening governance and
citizen engagement; 4) LANs; 5)
strengthening LGA human resource
systems; 6) Muungano gateway; 7)
GoTHOMIS; 8) PlanRep; 9) iMES;
10) improvements in PlanRep; 11)
PORALG and the digital revolution;
Exhibit 12: Cover Pages of the Joint PS3 and PORALG Newsletters
“The best news of the year for me
was the production of the FFARS
video manual. When the video
manual came out in December 2018,
I personally took the initiative of
downloading it and sharing it with all
health facilities of Mkalama, and
everyone was ecstatic. The face-to-
face training happened a year ago, so
obviously users had forgotten parts of
the process, but now with this video
manual, they can easily refresh their
memory and use the system following
the step-by-step instructions.” Omary
Mtamike, Information Officer –
Mkalama.
46
and 12) LGRCIS. Mifumo Yetu continues to be disseminated widely through ministry and RS/LGA
websites, as well as to other stakeholders. PORALG has taken over the newsletter and plans to
continue to produce it to inform stakeholders about strengthened systems and their use.
6. PROGRAM MANAGEMENT
PS3 functioned efficiently and effectively to implement a wide range of integrated system
strengthening interventions. A strong foundation was laid in Years 1 and 2 for concentrated
development and deployment of strengthened systems, with PS3 reaching its peak of
implementation intensity in Year 3. In Year 4, implementation shifted to deepening system use
and institutionalization, and eventually project close-out.
The complexities of PS3 operations in 13 regions and 93 LGAs, coupled with rapidly accelerating
program implementation, required strong program management. Regional clusters were the PS3
unit of operation, with about half of the 100 project staff based in regions or LGAs. The six
regional clusters (illustrated
in Exhibit 13) were: East
Southern Highlands area
(Iringa and Njombe), West
Southern Highlands area
(Mbeya and Rukwa),
Central area (Dodoma and
Morogoro), Southern area
(Mtwara and Lindi),
Western area (Kigoma and
Kagera), and Eastern Lake
(Mwanza, Shinyanga and
Mara). Each cluster
consisted of two to three
regions with regional
program managers and at
least one information
systems, finance, HR, and governance mentor to
integrate systems
strengthening across
components or systems
functions. Regional clusters met monthly to plan, budget, manage, report, and communicate,
including with GOT regional and LGA focal persons.
In addition to the regional structure, PS3 continuously strengthened the relationship between
national and regional/LGA teams, technical and management teams, across components, and
across partners. This ensured the project was responsive to USAID and GOT priorities,
ultimately maximizing PS3 impact and sustainability. PS3 also established its values and
continuously incorporated them into program management. For example, a staff-wide training
was held to build a common understanding of central tenants of gender equity and gender
relations. Internal communication was a priority using multiple mechanisms including meetings
Exhibit 13: PS3 Regional Clusters
47
(e.g., all-staff meetings, regional cluster meetings, and component technical team meetings),
reports, the Jamvi internal platform, and communication applications developed by technical staff
working groups.
Continuous improvement in management systems and processes produced efficiency gains and
enabled explosive growth in interventions, maximizing the impact of USAID funding while also
ensuring compliance with financial policies and procedures. Operational efficiencies included 13
regional offices embedded in existing GOT offices (no rent costs), and cost-sharing both rent and
office operating costs in Dar es Salaam office. The PS3 Finance Report is contained in Annex 3.
7. CHALLENGES & WAY FORWARD
7.1 Challenges
PS3 faced no major challenges throughout project implementation—no substantial problems or
barriers undermined PS3 progress towards results. However, due to its size, complexity,
collaborations, and multi-sectoral work across all levels of government, operational challenges
were continuously identified, managed, and resolved by PS3. Many challenges were related to the
fast pace of program implementation, which put pressure on GOT and PS3 systems, processes,
and staff. The joint PS3/GOT response was to continuously focus on efficiency, communication,
management, collaboration, and institutionalization. GOT and PS3 relationships were excellent.
However, periodic challenges emerged in relation to: replacement of high-level officials and
turnover of technical staff; relationships between government ministries; communication;
scheduling; and integrating implementation of interventions. Many of these challenges were
outside PS3’s control and were monitored and mitigated to the greatest extent possible with a
focus on communication at LGA, regional, and national levels. PS3 also focused on “the right
institution doing the right thing” to address relationship issues across and within GOT ministries,
departments, and agencies. The impact of COVID-19 on PS3 implementation was minimal as the
project was already in closeout when lockdown occurred in Tanzania.
Remarks from USAID Representative at all-PS3 Staff Meeting (at left), and Joint GOT and PS3 Planning Meeting
(at right).
48
Technical challenges arose continuously during PS3, with the vast majority of issues resolved
quickly by dialogue or implementation sequencing (or both). Longer-lasting or more substantial
technical program challenges and their resolution included the following:
Simplification of WISN and its use by LGA staff: after about two years of dialogue and analysis, convergence between MOHCDGEC and PORALG enabled
simplification of WISN and the use of WISN plus POA at LGA level to distribute
nationally allocated staff to facilities.
SNHI delays: dialogue helped keep stakeholders informed and build consensus about
complex technical issues; the time was used productively by PS3 to support DFF
implementation, which prepared facilities for the output-based payment and financial
management systems required for SNHI to succeed.
RBF delays: challenges arose due to program operation and MOFP delays; issues were partially addressed but full resolution was still in progress at the time of writing. The
opportunity was taken to reduce fragmentation in DFF and RBF payment, information,
and quality assurance systems.
PORALG Muungano Gateway and MOHCDGEC HIM: complex technical issues
and unclear roles emerged related to interoperability between these two information
mediators. It also affected system interoperability between PlanRep and HMIS/DHIS2 for
development of health plans, and interoperability between GoTHoMIS, eLMIS, DHIS2,
and NHIF claims management for DFF facility financial management and procurement of
medicines. PORALG, MOHCDGEC, other US Government projects, and PS3
information system specialists rose to the challenge and resolved the problems in Years
4-5.
Roles, Relationships, and Institutionalization: many of PS3’s technical challenges were related to institutionalization of strengthened systems into GOT functional and
sectoral/program entities (i.e., the “business process owners”) and their operations.
Most issues related to the inherent nature of organizational or human behavior change
as public sector service management and delivery was transformed. Very few of the
challenges were related to the systems themselves, as they were desired by
stakeholders, and efficiency gains and management improvements were recognized
broadly. GOT and PS3’s productive relationship was further enhanced by identification,
communication, and resolution of behavior change management issues, specifically those
related to realignment of roles and relationships.
7.2 Way Forward
PS3 worked with GOT to introduce a transformational systems strengthening strategy that
shifted money, systems, and people to over 24,000 health facilities and schools. The shift ignited
the ability of schools and health facilities to operate as management entities with the mandate
and authority to better serve their clients. The impact of GOT and PS3 interventions was a
dramatic improvement in service management, efficiency, transparency, and equity, with
greater autonomy and increased accountability—Exhibit 1 illustrates this dramatic
transformation, from run-down, empty, and unused facilities, to vibrant health facilities and
schools empowered and able to meet the needs of their communities.
49
While PS3 has made great strides in strengthening cross-sectoral PFM, and improving health and
education front-line management and service delivery, challenges persist. Extending the use of
strengthened PFM systems to the village level to serve all public sectors, increasing citizen
engagement in the planning and oversight of services, and expanding payment reform to other
sectors are important next steps in Tanzania’s journey to self-reliance. For example, budgets in
agriculture, water, or other public sectors are usually based on and disbursed by an estimate of
inputs and result in the distribution of an inappropriate mix of inputs with minimal flexibility,
transparency, autonomy or accountability for front-line service providers to manage delivery of
service outputs to citizens and communities. This approach to PFM undermines the management
capacity of public providers, excludes the potential contribution of the private sector, and limits
effective means to identify the needs of priority groups, including poor, women and youth, or the
resources to address them.
Many of the interventions used by PS3 are transferrable. For example, the use of interoperable
systems (PlanRep and FFARS) gives front-line providers across sectors a platform to develop
their own plans and budgets. Use of an output-based payment formula shifts the focus of
budgeting away from inputs onto the resources needed to best serve the complex and cross-sectoral needs of citizens. Output-based planning, budgeting and payment also helps address
barriers to poor, gender and youth inclusion by making priority groups more visible in plans and
budgets with payment better matched to these services, and therefore LGAs and providers
accountable for delivering services to them. Furthermore, ensuring front-line providers,
managers, and governance structures have the tools to gather input ensures that they can identify
the barriers that prevent certain groups from fully participating in economic, political, and social
life, and that they reach the right people with the right services.
Next steps to deepen the results of the productive GOT and PS3 partnership should include:
1. Further strengthening to consolidate the gains made in public sector management and
the health and education sectors;
2. Extending into new sectors and to reach more citizens; and
3. Continuing the handover of financial and programmatic responsibility for PS3 areas of
support to ensure Tanzania is able to sustain delivery of efficient, equitable, and
responsive quality services particularly for underserved populations.
50
ANNEXES
Annex 1: PS3 Indicators Target and Results
Note: indicators without Year 5 result are either completed or data from GOT systems is not yet available due to fiscal year end June 30th
Key: Abbreviation Meaning
BL Baseline
RSL Result
TGT Target
Y1 Year 1 (FY 2015/16)
Y2 Year 2 (FY 2016/17)
Y3 Year 3 (FY 2017/18)
Y4 Year 4 (FY 2018/19)
Y5 Year 5 (FY 2019/20)
Done Complete and
closed
NA Not Available
51
M&E Plan: Outcome/Impact Indicators
# Indicator Name BL Y1
RSLT
Y2
TGT
Y2
RSLT
Y3
TGT
Y3
RSLT
Y4
TGT
Y4
RSLT
Y5
TGT
Y5
RSLT
1.1 % of citizens report satisfied by LGA services (USAID
collect)
1.2.a % change in PE per capita expenditure in LGAs 7.4% 41.6% 12.1% 7.4% 7.0% -1.0% 3.0% -7.4%
1.2.b % change in equity in distribution of PE across LGAs 80.0% -65.2% 125.7% 2.6% 3.0% 7.6%
1.3.a % change in OC per capita expenditures in LGAs -
27.7% 3.5% 6.0% -22.5% 3.0% 31.0% 3.0% -15.7%
1.3.b % change in equity in distribution of OC across LGAs -
10.4% 16.7% -29.1% 3.9% 3.0% NA
1.3.c % change in the ratio of OC to PE in LGAs -
32.7% -26.9% -27.9% 32.4% 3.0% -9.0%
2.1.1 % of LGAs that incorporate feedback from citizens 74.7% 75.3% 77.0% 94.6% 80.0% 98.9% 98.9% 94.6%
2.1.2
% of citizens believe citizen participation is effective in
making government more responsive to citizen needs
(USAID collect)
2.2.1 Retention rates of recruited service provider staff (started
Y3) 65.0% 64.6% 66.0% 99.3%
2.2.2 % of LGAs with nurse ratios ≥ 3/10,000 - PAF (USAID) 71.9% 71.9% 72.0% 69.6% 72.0% 66.3% 68.0% 73.1%
2.2.3 % of LGAs teacher-pupil ratio 1:≤ 45 in primary schools
(USAID) 53.3% 47.5% 75.0% 22.8% 28.0% 18.0% 19.0% 17.2%
2.3.1 % of expected RBF funds received by each facility 32.0% 47.4% 50.0% 66.3% 70.0% 81.5% 83.0% 89.0% 85.0% 82.9%
2.3.2 % of approved budget transferred central to LGAs 70.7% 81.5% 85.0% 74.1% 76.0% 73.5% 75.0% 72.2%
2.3.3 % of OC funds disbursed from central or LGAs to facilities 0.0% 0.0% 0.0% 0.0% 80% 78.6% 81.0% 63.1%
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M&E Plan: Intermediate Indicators
# Indicator Name BL Y1
RSLT
Y2
TGT
Y2
RSLT
Y3
TGT
Y3
RSLT
Y4
TGT
Y4
RSLT
Y5
TGT
Y5
RSLT
3.1.1 % of women serving on facility governing committees 31.6% 32.0% 36.0% 32.0% 34.0% 34.1% 36.0% 36.0%
3.2.1 % of total public payments contracts private providers 22.8% 2.8% 3.0% 2.1% 3.0% 1.8% 2.5% 4.1%
3.2.2 # of agriculture public-private dialogue events 0 0 4 5 9 12 Done
3.3.1.a PlanRep redesign completed 0 0 0 1 Done
3.3.1.b % targeted LGAs using redesigned PlanRep 0.0% 0.0% 0.0% 0.0% 50.0% 100.0% Done
3.3.2 % of service providers in LGAs with Epicor codes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 90.0% 100.0%
3.3.3.a % of targeted LGAs submit permit allocation request based
on POA 0.0% 0.0% 0.0% 0.0% 10.0% 0.0% 30.0% 0% 50.0% 100.0%
3.3.3.b POPSM prioritization methodology basis allocation of staff to
LGAs 0 0 0 0 0 0 1 1
3.3.3.c % of targeted LGAs who have distributed staff based on
POA 0.0% 0.0% 0.0% 0.0% 10.0% 60.2% 65.0% 100.0%
3.3.4 % of LGAs with clean audit reports 25.0% 82.0% 79.6% 83.0% 93.6% 83.9% 93.6% 90.3% 96.8%
3.3.5 % of LGAs submitting complete reports on time 43.8% 36.8% 40.0% 40.9% 50.0% 39.6% 50.0% 100.0%
M&E Plan: Output Indicators
# Indicator Name BL Y1
RSLT
Y2
TGT
Y2
RSLT
Y3
TGT
Y3
RSLT
Y4
TGT
Y4
RSLT
Y5
TGT
Y5
RSLT
4.1.1 % of LGAs using website to share information with citizens 0.0% 0.0% 10.0% 23.7% 75.0% 79.6% 80.0% 83.9%
4.1.2 % increase in LGA committee benchmarking scores 0.0% 0.0% 0.0% 0.0% 10.0% 78.6% 10.0% 3.2%
4.1.3 % of LGAs strengthened internal audit system 0.0% 0.0% 0.0% 0.0% 9.7% 9.7% 9.7% 9.7% 20.0% 9.7%
4.2.1 % of targeted LGAs strengthened records management
system 0.0% 0.0% 0.0% 23.3% 50.0% 80.0% 90.0 100.0%
53
4.2.2 % of newly reported staff receiving a job orientation using
new manual 0.0% 0.0% 10.0% 0.0% 30.0% 58.8% 65.0% 54.4%
4.3.2.a % of LGA service providers oriented on use of FFARS 0.0% 0.0% 90.0% 99.4% Done
4.3.2.b % of LGA service providers upload data to FFARS 0.0% 0.0% 0.0% 0.0% 50.0% 97.7% 97.7% 99.7%
4.3.3 % change in absolute level of LGA OSR 20.5% 10.6% 4.0% 3.7% 5.0% 16.0% 5.0% 35.0%
4.4.1 % of 7 sets of priority systems made interoperable 0.0% 0.0% 0.0% 0.0% 0.0% 57.1% 71.0% 57.1% 85.7% 85.7%
4.4.2 % of targeted LGAs that strengthened LANs 0.0% 0.0% 0.0% 100.0% Done
4.4.3 % of LGAs with multi-sectoral dashboard systems 0.0% 0.0% 10.0% 0.0% 10.0% 0.0% 80.0% 100.0%
5.1.1 # of operations research Studies completed 0 0 2 2 5 4 8 4 9 5
5.1.2 # of operations research findings disseminated, disaggregated
by policy briefs and articles submitted to peer-review journals 0 0 0 0 1 1 3 1 5 3
P-3 # of LGAs with customized retention packages 26 26
P-5 % of targeted LGAs who submit LLG plans into PlanRep 28.0% 100.0%
P-6 # of key HIV policies PORALG contributed to the operational
roll out. 6 4 6 6
P-7 % of health facilities paid using new/improved output-based
payment 80.0% 98.5%
Nutrition Indicators
# Indicator Name BL Y4 TGT Y4 RSLT
N-1 EG.3.1-d Milestones in improved institutional architecture for food security policy achieved with USG support [Multi-level] 0 10 69
N-2 CBLD-9 Percent of USG-assisted organizations with improved performance [IM-level] 0 30.3% 100%
N-3 HL.9-4 Number of individuals receiving nutrition-related professional training through USG-supported programs 0 155 368
N-4a NMNAP Proportion of councils using bottleneck analysis and scorecard findings to undertake planning, budgeting and reporting that is
evidence-based. 0 30.3% 0.0%
N-4b # of LGAs using automated scorecard findings to undertake planning, budgeting and reporting that is evidence-based 0 NA NA
N-5 % increase in LGA PlanRep budget under nutrition objective NA NA NA
54
Annex 2: PS3 Contractual Deliverables
Quarterly Reports Annual
Reports
Workplans Success Stories Other Reports
2015_October 1 - December 31 Year 1 Quarter 1
PS3 Quarterly Report
2016_ January 1 - March 31 PS3 Year 1 Quarter 2
Quarterly Report
2016_April 1 - June 30 PS3 Year 1 Quarter 3
Quarterly Report
2016_Oct 1 - Dec 31 PS3 Year 2 Quarter 1
Quarterly Report
2017_ Jan 1 - March 31 2017 PS3 Year 2 Quarter 2
Quarterly Report
2017_April 1 - June 30 2017 PS3 Year 2 Quarter 3
Quarterly Report
2017_October 1 - December 31 PS3 Year 3
Quarter 1 Quarterly Report
2018_April 1- June 30 PS3 Year 3 Quarter 2
Quarterly Report
2018_January 1 - March 31 PS3 Year 3 Quarter 3
Quarterly Report
2018_October 1-December 31 PS3 Year 4 Quarter
1 Quarterly Report
2019_April 1- June 30 PS3 Year 4 Quarter 2
Quarterly Report
2019_January 1- March 31 PS3 Year 4 Quarter 3
Quarterly Report
2020_April 1- June 30 PS3 Year 5 Quarter 2
Quarterly Report
PS3 Year 1
Annual
Report
PS3 Year 2
Annual
Report
PS3 Year 3
Annual
Report
PS3 Year 4
Annual
Report
PS3 Year 1
Workplan
PS3 Year 2
Workplan
PS3 Year 3
Workplan
PS3 Year 4
Workplan
PS3 Year 5
Workplan
Direct Health Facility
Financing to Improve
Malaria Service Delivery
PlanRep and FFARS as the
Bookends of Facility
Autonomy for Improved
Malaria Service Delivery
The Solution to a Persistent
Health Workforce
Challenge
Workforce Allocation and
Distribution to Meet
Malaria Service Delivery
Requirements
Addressing Tanzania’s
Critical Health Worker
Shortage: Prioritizing
Workforce Distribution
According to Need
Effects of Reforms and Systems
Strengthening on Health Facility and
School Management Governance
(Qualitative Operations Research
Study)
Gender Assessment of Phase 1 LGAs
Final Report
PS3 M&E Plan_PIRS Revision_March
27 2019_Final
55
Annex 3: Contract and Financial Management
61,909,701 560,099 74,751
Component 1 5,804,825 178,234 5,983,059
Component 2 4,863,108 140,781 5,003,889
Component 3 4,013,098 143,839 4,156,937
Component 4 2,601,051 115,193 2,716,243
Component 5 2,065,111 68,556 2,133,668
Component 6 8,556,432 237,592 8,794,024
Other Costs 17,868,879 313,694 18,182,573
Indirect Costs 10,926,902 326,201 11,253,103
Total Estimated Costs 56,699,404 1,524,092 58,223,496
Fixed Fee 3,028,977 97,129 3,126,106
Total Cost Plus Fixed Fee 59,728,381 1,621,221 61,349,602
Unobligated
Balance of
FundsLine Items
Total Funds
Awarded to Date
Total Funds
Previously Reported
As Expended
Total Funds
Expended
This Quarter
Cumulative
Expenditures
Total
Unliquadated
Obligations
LOE Year
1,2,3,and 4
LOE Previouly
Expended
Projectd LOE
This Period
Cumulative
LOE
Total LOE 76,083 83,007 617 83,624
*Please note that final invoicing is still in process, and these numbers are not final.
$61,984,452
Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-30 Jul-20 Aug-20 Sep-20
1 Component 1 5,871,388 5,647,563 9,976 55,956 65,909 107,957 33,384 36,893 66,174 0 0
2 Component 2 5,176,136 4,706,681 63,408 103,757 150,894 33,490 38,881 68,410 85,776 0 0
3 Component 3 4,480,978 3,907,561 36,592 54,472 66,763 37,498 70,426 35,915 65,566 0 0
4 Component 4 2,747,566 2,524,078 18,905 50,149 40,936 33,267 48,861 33,065 63,793 0 0
5 Component 5 2,290,274 2,054,342 5,269 38,909 31,545 35,798 7,104 25,654 59,184 0 0
6 Component 6 (Cross Cutting) 9,021,289 6,813,003 380,499 88,119 285,903 43,263 84,868 109,462 74,994 0 0
7 Other Direct Costs 16,802,176 18,030,879 175,382 268,038 80,917 10,489 126,479 176,726 109,913 0 0
8 Indirect Costs 12,288,477 10,469,972 133,754 170,654 171,645 96,091 117,592 112,518 69,979 0 0
9 Total Estimated Cost 58,678,284 54,154,080 823,786 830,054 894,512 397,853 527,594 598,644 595,378 0 0
10 Fixed Fee 3,231,417 2,931,421 6,239 34,586 57,275 38,967 35,359 22,803 14,182 0 0
TOTAL (USD) 61,909,701 57,085,500 830,025 864,639 951,787 436,820 562,953 621,447 609,560 0 0
A Funds obligated to date (from above) 61,909,701 0
B 61,353,172
C 556,529 0
D Less: Projected expenditures by end of next quarter (from above) 609,560 Notes:
E
F -53,032 AOR/COR Estimated Monthly Expenditure Rate for next 12 months
G 711,279 (if different from next quarter's monthly projected burn rate ):
H 203,187
I 1 AOR/COR Name and Signature: Date:
J 3
K 0
For USAID COR / AOR use:
a. Expenditures through current quarter (from above)
PREVIOUS QUARTER EXPENDITURES CURRENT QUARTER EXPENDITURES
1,621,221 609,560
Expenditures to
Dec 31, 2019No. Budget Line Items
NEXT QUARTER PROJECTED EXPENDITURESObligated to
date
For AOR/COR Accrual Calculation:
2,646,451
c. Accrual amount [c = a - b]
b. Less: Total disbursements per Phoenix
Projected pipeline (months) end of next quarter based on projected burn rate [K = F/H]
Current pipeline (months) based on historical burn rate [I = C/G]
Monthly historical burn rate (average from past six months)
Monthly projected burn rate (average from next quarter's three months)
Less expenditures through current quarter (from above)
Current Pipeline: funds reamaining at the end of current quarter [C = A - B]
Add: Projected incremental funding by end of next quarter (per AOR/COR)
Projected pipeline at end of next quarter [F = C - D + E]
Projected pipeline (months) based on projected burn rate [J = C/H]
For quarter ending: June 30, 2020USAID/TANZANIA Implementing Partner Actual and Planned Expenditures Project/Activity Name: Tanzania Public Sector Systems Strengthening (PS3)
Award end date: 07/28/2020Award start date: 07/29/2015 Total Estimated Cost of Award (TEC):
Name of Organization: Abt Associates
Award #: AID-621-C-15-00003
56
Annex 4: Local NGO Table
Description of all nongovernmental institutions PS3 worked with in connection with program
components and an evaluation of their strengths and weaknesses (local subcontractors).
Organization Program
Areas Strengths Weaknesses
Benjamin William
Mkapa Foundation
(BMF)
Human
Resources
(HR)
Human resource technical
content, policy dialogue,
environmental knowledge and
linkages, LGA operations
Favored separate or vertical
operational mode but shifted to
supporting program integration
over time, also strengthened
management functions over time
Local Government
Training Institute
(LGTI)
Governance,
HR, training
GOT institution with mandate
to train LGA public workers,
training capability and
commitment, well-managed
Scheduling issues could emerge
at times due to GOT routine
work but developed processes
and coordinated well over time
Tanzanian
Mentors for
Action (TMA)
Information
systems,
finance,
governance
Excellent information systems,
finance and governance
technical capacity, ability to
work at region/LGA level, very
proactive, very well-managed
Minimal organizational
weaknesses, and if issues emerge
they are quickly addressed by
proactive management
University of Dar
es Salaam (UDSM) Finance
Technical expertise, ability to
combine academic and practical
or field finance perspectives
Scheduling issues could emerge
due to academic schedule but
developed processes and
coordinated well over time
PUBLIC SECTOR SYSTEMS STRENGTHENING
(PS3) IN TANZANIA
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