HISTORY

Often times people are told by government officials that there are limited financial resources to finance different
development projects/programmes and to provide assistance for self help. This view is also held by the academic
world. This is usually taken as an absolute truth and usually as an excuse for the limited socio-economic
development of the citizens and societies. While this may be true, we propose a problematisation of this by
gathering and making sense of evidence from the annual audit reports for the Local Government Authorities
(LGAs) in Tanzania. The central aim of the paper therefore is to show the fallacy of “the limited
resources” by arguing that it is not a matter of limited resources but whether and how the available resources are
put to intended use for development and poverty reduction goals. The relevance of this is to shift focus on
development resources available to whether and how the extent to which the resources are put to use and to
establish whether LGAs are keeping people into poverty by using or not using the available resources.

Background: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country's level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. Methods: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. Results: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. Conclusion: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance. Implications for policy makers • The regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers. • The MoHSW should provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance. • The MoHSW and the Ministry responsible for regional administration and local government need to make sure that incentives to the health providers, Health Facility Committees (HFCs) and board members are available and paid in time. Implications for the public In order to effectively implement community-based health insurance, there is need to actively engage all stakeholders, including the public in the implementation of policies at the local level. The public, through health facility (user) committees should actively participate in monitoring the availability of quality health services in the health facilities.