Direct health facility financing and its influence on quality compliance in primary healthcare: evidence from Tanzania.

Background: Globally, health systems focus on improving the quality of healthcare services through policy changes. Sub-Saharan African countries have been enacting reforms to strengthen their primary healthcare and referral systems including devolution of authority to healthcare facilities. Devolving health facility financing to primary healthcare providers is a crucial strategy to enhance autonomy in planning, management and resource utilization. In Tanzania, this strategy is called Direct Health Facility Financing (DHFF), and is envisaged to impact on the quality of health services in primary healthcare facilities. This study aimed to determine the effect of DHFF on quality of health services after 3 years of its implementation.

Methods: This study employed a before-after noncontrolled analysis of the quality scores by considering compliance of public primary health facilities with healthcare quality standards by using star rating assessment data before and after DHFF implementation. Quality scores were established by performance of service areas, namely organization of services, emergencies and referrals; infrastructure, infection prevention and control; clinical services; and clinical support services. Distribution normality of compliance scores was determined through the Shapiro-Wilk test for normal data and were observed to be non-normal. Median change in quality compliance scores were established, Wilcoxon matched pairs sum rank tests estimated probabilities of the change (α = 0.05) and Cohen's d estimator (d) calculated the effect size of DHFF.

Findings: This study involved 1216 primary healthcare (PHC) facilities from 10 regions of Tanzania's mainland, the majority of which were dispensaries (88.8%) and rurally located (86.3%). Findings showed significant positive median change in compliance with quality standards from 0.53 to 0.57 (P < 0.001). However, effect size of DHFF as an intervention is small (d = 0.27).

Conclusions: Direct health facility financing has impacted a small change in quality of health services. As evidenced by several studies, challenges regarding fidelity to its implementation process including lower spending on health commodities, dependence on and delayed disbursement of Health Sector Basket Funds (HSBF), poor facilities' planning capacity and shortage of human resources for health must be addressed for it to yield its intended outcome.