Value for money? : the efficiency of primary health units in Tanzania
This thesis reports on a multi-disciplinary evaluation of primary level health units, undertaken in Tanzania The research objectives were to evaluate the provision of primary level health care in order to develop recommendations for its improvement and appropriate methods for such assessment at district level. The evaluation used the technique of cost analysis together with specific review of structural and process quality and of the community's satisfaction with the available care, in order to assess production efficiency. An initial group of 58 health units, including both dispensaries and health centres, and government and voluntary agency units, were evaluated in the cost and structural assessments. Process quality was assessed in a sub-sample of twenty units, and community satisfaction in relation to a further subsample of ten units. The range of unit types was maintained at each stage of the study. This study's analysis indicates that these units were inefficient, characterized by poor productivity, limited structural, and weak process, quality. They were also poorly perceived by the community. Health centres were relatively expensive but of poor quality. Voluntary agency units performed no better than government units, and sometimes worse. The study's conclusions point to the need for better management of available resources to bring about more efficient, better quality care. The inadequacy of currently available resources was found to underlie some performance failures but an equally important problem was the weakness of the organizational structure of the health system. The research findings indicate the potential for efficiency savings, as well as considering the additional resources that might be generated through the introduction of user fees at the primary level. However, this potential will only be tapped if structures that encourage flexible and effective management are developed. The methods of this research could be used to strengthen managerial practices, either being adapted for use in other research studies or for monitoring at the district level. Similar research is required to support the development of management structures and systems.