Tanzania: Organizing the private health sector
When the private sector is fragmented or lacks a representative voice, it is difficult to take into account its interests and contributions to national and local policy and regulation.11 The private sector in turn misses out on opportunities to contract with the government, obtain financial protection mechanisms, access training opportunities, and more generally become integrated into the larger health system. Promoting a more organized private health sector reduces the transaction costs of working with disparate groups and paves the way for effective public-private engagement.10 In Tanzania, SHOPS Plus worked with privately operated retail outlets that sell essential medicines to help them participate in credible and representative associations that could advocate for their interests, communicate their needs, and ultimately provide a uniform voice to interact with the government.
Context
Photo: Christina Kramer
Accredited drug dispensing outlets (ADDOs) are frontline providers in Tanzania’s health system and important sources of health products and services, including family planning and child health products. There are more than 9,000 ADDOs country-wide, and about one-third of Tanzanians with an acute illness go to an ADDO first for treatment.12 However, these providers face important challenges. First, they have no ability to represent themselves in national policy dialogue and thus cannot ensure that the regulations and strategies that shape their operating environment accurately reflect their concerns. For example, owners and operators are often left out of debates about drug sellers’ scope of practice and the range of medicines that ADDOs can legally sell. This has resulted in discrepancies across several government policies and guidelines about what types of family planning methods they are allowed to carry. Second, the emergence of these outlets throughout the country—due to limited supervision and enforcement of regulations—threatens the quality of their products and services, and in turn raises concerns among regulators and community members about the value and credibility of ADDOs. The first two challenges are compounded by a lack of clear understanding on the part of many ADDO owners and operators of the role of various government regulators. Finally, these outlets are generally not included in government-sponsored or community-based health financing schemes, meaning that their clients must rely on out-of-pocket payments. This can be a barrier to seeking care.
Approach
Following a situational analysis and stakeholder engagement process, SHOPS Plus identified an opportunity to create a strong local ADDO association in the Nyamagana district. Among other benefits, the association would provide individual outlets a voice in shaping the operating environment in district, regional, and national policy dialogues. It would enhance their ability to partner with district and regional government supervisors to improve reporting and the quality of products and services among association members. In addition, it would help provide a channel for contracting opportunities with government-sponsored or community-based health financing programs. By focusing first on a district-level association, the project intended to demonstrate how this concept could promote improved public-private engagement before scaling up the approach to other districts and the national level.
The point of the association is to have one voice, as we are stronger together and can influence changes compared to an ‘every man for himself’ approach.
Secretary of the Nyamagana Health Support Foundation
A SHOPS Plus primer outlines key principles for successfully organizing the private sector, based on various country experiences.11 One important first step is to articulate and communicate the value of a more organized private health sector, and convince stakeholders of the benefits to their businesses of organizing. Accordingly, SHOPS Plus implemented a two-phase process to help establish the ADDO association.
Phase 1: Stakeholder engagement
In phase one, the project focused on public-private dialogue. SHOPS Plus staff engaged key stakeholders—ADDOs, regulators, suppliers, community members, and others—to build consensus around the need for an association to represent the outlets’ interests. This effort started with one-on-one meetings for leaders of the district health teams and among ADDO owners. SHOPS Plus brought together representatives from both sectors in group meetings to identify gaps and create potential solutions. Initially, public sector officials were apprehensive of the association’s purpose and were concerned that it would weaken their attempts to hold ADDOs accountable. Continuous facilitation efforts between public and private sector representatives helped to build understanding and trust among the various parties involved.
Phase 2: Technical assistance
During the second phase, the project provided direct technical assistance to ADDO owners and operators to launch and manage the association. Most owners and operators lacked the leadership skills necessary to form an association and drive a public-private engagement agenda forward. The project provided technical assistance to help the association’s leadership agree on an organizational and governance structure, develop and implement tools and guidelines, create a strategic plan and budget, and pursue its legal registration.
As a result of these efforts, the Nyamagana Health Support Foundation (NHSF) became a registered association in 2017, fully funded by ADDO member registration fees and revenue from other services. These services include selling new branded products, expanding revenue from pooled procurement, and setting up a cyber café that provides members with internet services. The foundation has helped the ADDOs in Nyamagana district to improve their engagement with the public sector in the following ways.
- The Pharmacy Council of Tanzania is supporting the NHSF as a mechanism for peer regulation, improved reporting, and quality assurance.
- The NHSF gained representation at stakeholder fora such as the Tanzania Public Private Health Forum.
- ADDOs in Nyamagana district participated in a pilot with the Pharmaceutical Society of Tanzania and the Reproductive and Child Health section of the Ministry of Health to dispense oral contraceptives and emergency contraceptives to generate evidence for policy change.
- The NHSF leadership has become an advocate for stronger organization of ADDOs into associations at the district, regional, and national levels.
These successes have helped garner broad consensus on the need to set up regional chapters of the association, and eventually a national ADDO association. To that end, SHOPS Plus has helped establish an interim board to get the process started. Using a similar two-phase approach, and backed by strong local leadership, the Pwani Medication Awareness Organization was established as a regional ADDO association in Pwani region in 2019.
| Lessons learned |
|---|
| Efforts to organize and strengthen the voice of the private sector need to go beyond the sector itself. If public stewards and regulators are engaged early on to help identify problems and solutions, they will be more likely to support the organizing effort and view the private sector organization as a legitimate partner for engagement. Private providers may see more value in participating in the organizing effort if the government is involved. |
| By narrowing the focus on a specific problem, opportunity, or geographic area, organizing efforts can dedicate sufficient time and resources to ensure the initial efforts are successful, thereby creating momentum for broader engagement down the line. Once success is proven, organizing efforts can more effectively expand the geographic scale of membership and the technical scope of activities. |