Do health facility governing committees improve health system performance? An ecological study of Mainland Tanzania

Abstract

Introduction: Accountability is crucial for improved functionality of health systems and can be ensured through community participation in health governance. To engage the community in the governance of the local health system, health facility governing committees (HFGCs) have been implemented in several low-income and middle-income countries including Tanzania. However, the effect of HFGCs on health system performance is not well studied. The aim of this study was to investigate the relationship between the functionality of the HFGCs and health system performance in 180 districts of mainland Tanzania, and to assess whether this relationship varies between dispensaries, health centres and hospitals.

Methods: We conducted an ecological study in which the studied outcome was health system performance. The main independent variable was functionality of HFGCs, that is, to what extent these committees reflect the concerns of and connect back to the community. Other explanatory variables included staff availability, location of the facility, gender of the manager of the facility and ownership of the facility. Data on all of the variables were retrieved from the Star Rating Assessment of 2017/2018, measured as mean proportions of all facilities in the districts. The analyses included linear regression for all facility levels combined, as well as for the levels of facility separated (dispensaries, health centres and hospitals).

Results: We found a positive relationship between the functionality of the HFGCs and health system performance (β=0.53; 95% CI=0.47 to 0.60). The relationship was stronger for dispensaries (β=0.56; 95% CI=0.50 to 0.63) compared to health centres (β=0.39; 95% CI=0.33 to 0.44) and hospitals (β=0.23; 95% CI=0.15 to 0.31).

Conclusions: Districts that have functional HFGCs tend to have better health system performance than others. This relationship is stronger in dispensaries compared to health centres and hospitals. Therefore, we believe the district authorities should allocate resources to strengthen the HFGCs.

Keywords: Accountability; Africa South of the Sahara; Health systems; Health systems evaluation.

Figure 1. Descriptive maps of Tanzanian districts picturing the functionality of HFGCs and the performance of the healthcare system (Baroudi, 2024). HFGCs, health facility governing committees.

Figure 2. To the left is a scatterplot with univariable linear regression, including CI. Data of all facility levels. (Pearson r=0.70). Each datapoint represents one Tanzanian district. To the right is a combined scatterplot with univariable linear regression, with data stratified for level of facility. Each datapoint corresponds to one Tanzanian district. HFGCs, health facility governing committees.