Role of Public-Private Partnership in the Availability of Essential Medicines at Health

Facilities in Ubungo Municipality, Tanzania.

Hezron Aggrey Msongole1,2*, Mackfallen Anasel3, Omary Swalehe3, Francoise Mukanyangezi1,

Theogene Rizinde1, Maganga Hashimu Shimbi4, Bonaventura Nestory5, Peter Nsanya2

EAC Regional Centre of Excellence for Vaccines, Immunization, and Health Supply Chain
1

Management, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
2
Health Department, Ubungo Municipal Council, Dar es Salaam, Tanzania.
3
Dar es Salaam Campus College, Mzumbe University, Tanzania.
4
MHS Consults Limited, Dar es Salaam, Tanzania.
5
Ministry of Health, Dodoma, Tanzania.

*Corresponding Author: Hezron Aggrey Msongole

Email: mheizron@yahoo.com

ABSTRACT

Background of the study

The availability of essential medicines is a critical component of universal health coverage and is

vital in addressing patients' satisfaction and increasing their health-seeking behavior. In

Tanzania, the acquisition, storage, and distribution of medicines and medical supplies to health

facilities are the responsibility of the Medical Store Department (MSD), a government-semi-

autonomous institution. However, similar to the central medical stores in other countries, the

MSD in Tanzania needs to supply essential medicines to health facilities.

Objectives

This study aims to identify the role of public-private partnership (PPP) in the availability of

essential medicines at health facilities in Ubungo Municipality, Tanzania.

Methods
This descriptive cross-sectional study was conducted among health workers at randomly sampled

health facilities. The structured questionnaires and interviews were used to collect information

from the staff at the dispensing areas to assess the role of the Public-Private Partnership (PPP) in

the availability of essential medicines.

Results

The findings of this study showed a strong positive relationship among PPP guidelines, PPP

awareness and PPP implementations to the availability of essential medicines at health facilities

in Ubungo Municipality with a correlation coefficient of 0.5523 when all independent variables

are combined and a variability of 30.5%. When all worked together, the three conventional

variables (PPP guidelines, PPP awareness and PPP implementation) will ensure essential

medicines' availability to patients whenever they visit health facilities.

Conclusion

Our study discovered a significant positive relationship between PPP guidelines, PPP awareness,

PPP implementations and the availability of essential medicines at healthcare facilities in

Ubungo Municipality, with a coefficient of correlation of 0.5523 and a variability of 30.5% when

all independent variables are combined.

Keywords

Public-Private Partnership, Essential Medicines, Medical Stores Department

1. BACKGROUND

The availability of essential medicines is a critical component of universal health coverage and is

vital in addressing patients' satisfaction and increasing their health-seeking behavior. The World

Health Organization (WHO) recommends that essential medications be available and accessible

at all times, in acceptable quantities, dosages, and qualities, and at an affordable price [5]. An

estimated two billion people do not have access to medications globally, and it has been reported

that around four million lives in developing countries would be saved annually if proper

treatment and medication were available [6]. However, inadequate forecasts, low financing,

delays in funding disbursements, and lengthy lead times (tendering and manufacturing) impair

the adequate supply of medicines to health facilities, particularly in developing countries [2].

In Tanzania, the acquisition, storage, and distribution of medicines and medical supplies to

health facilities are the responsibility of the Medical Stores Department (MSD), a government-

semi-autonomous institution. However, like central medical stores in other countries, Tanzania's

MSD has challenges supplying essential medicines to health facilities [1]. Additionally, the

Medical Stores Department (MSD) is responsible for purchasing, storing, and distributing

medications and medical supplies to healthcare facilities.

The MSD faces difficulties supplying essential medications to healthcare facilities [3], similar to

central medical stores in other nations [7]. The government and the private sector can only

provide some of the necessary health medications and equipment at the right time and at all

times. In many parts of the world, to speed up healthcare service delivery and cut costs, PPP

collaboration is essential to achieving the high standards that ensure public and private resources

are effectively used to meet the population's needs [3].

In Tanzania, PPP was adopted as part of the Heal1996 1999 to enhance health service delivering

delivery [4,8]. Following the adoption, private businesses supported the MSD in supplying

necessary medications to public health facilities nationwide through government-established top

vendors in each region. Before establishing a prime vendor system in 2018, public health

facilities received essential medicines from the private sector through competitive tendering [4].

The introduction of user fees, pre-paid systems, and health insurance programs were all part of

the Comprehensive Health Sector Reforms (HSR) which were put in place in response to the

Structural Adjustment Programs (SAPs) in the 1990s. The formalized partnership between the

public and private sectors sought to formalize non-profit organizations' participation in the

delivery of healthcare services, encourage private sector investment in healthcare, and increase

the quality and accessibility of healthcare services.

2. METHODOLOGY

2.1 Study design

This cross-sectional descriptive study was conducted among health workers in randomly selected

health facilities. The structured questionnaires and interviews were used to gather information

from health staff working at the dispensing areas and pharmacy stores to describe the role that

Public Private Partnership (PPP) plays in the availability of essential medicines at health

facilities in Ubungo Municipality.

2.2 Area of the study

was conducted in Ubungo Municipal Council, one of five districts of the Dar es Salaam Region

in Tanzania. It covers an area of 260.4 km2 and comprises fourteen wards sub-divided into 91

streets.
At the north, Ubungo municipality borders the Kinondoni and Kibaha districts of the Dar es

Salaam and Pwani regions, respectively. The Kisarawe district of the Pwani region borders it

from the west, and the Ilala district connects it from the south and east.

The Ubungo municipality is in charge of health services delivery to its residents in collaboration

with private and parastatal health services 208 facilities provide preventive, curative and

rehabilitative health, with 20 (9.6%) and 178 (90.4%) facilities being operated by the

government and the private sector, respectively.

2.3 Target and study population

Target and study population for the study comprised Public and private facilities available in the

study area, whereby a total of 40 health facilities were involved. Among the public health

facilities, two were hospitals, four were health centres and 16 were dispensaries. Staff involved

were in charge of health facilities, pharmacy stores, and pharmacy dispensers.

2.4 Sample size and sampling method

The total number of health facilities selection was guided by taking an equal number of all 20

public facilities and 20 private facilities within the council. Private facilities selection was based

on a similar number of health facilities level with the public (2 hospitals, 4 health centers, 14

dispensaries), totaling 40 health facilities. Private health facilities were selected randomly based

on similar levels to the public facilities.

For the quantitative part of the study, 39 pharmacy dispensers and 39 stores in charge of 40

health facilities were selected to respond to the questionnaires. While for the qualitative part of

the study, 40 facilities in charge were selected to participate in in-depth interviews.

2.5 Data collection tool and technique

The study used both open-ended and closed-ended questions for data collection. For the

quantitative part, the questionnaires had two major sections: the first was about the facility and

the respondent’s information. While the second section contained various questions on Public-

Private Partnership (e.g. purchasing of medicines, Storage of medicines, distribution of

medicines etc.) and availability (low cost, on-time delivery and desired quantity).

For the qualitative part of the study, the facilities in charge gave their views on guidelines,

awareness and implementation of the availability of essential medicines at their respective health

facilities.

2.6 Data analysis

The study used thematic and inferential data analysis to develop findings and derive conclusions.

Examined qualitative data where 40 health facilities in charge were interviewed. Thematic

analysis was used to analyze the qualitative data. They were finding an absolute number to sum

up each variable and identify a pattern that required analysis. The respondents' demographic

traits were summed up and described in this section using percentages. This enabled the

researcher to gather information from the respondents to accomplish the research goals and

respond to the research questions regarding the current study.

To demonstrate the relationship between various variables and to make predictions, inferential

statistics were used, where 78 pharmacy stores in charge and pharmacy dispensers were given

questionnaires. The hypothesis was tested for analysis using Pearson correlation and regression

analysis.
2.7 Ethical consideration

Before data collection, the study obtained ethical approval from the National Institute for

Medical Research (NIMR) in Tanzania and the University of Rwanda's (UoR), respondents'

private information, their identities for enrolling participants in the study, provided written

informed consent. To protect respondents' private information, their identities were only codes or

initials.

3. RESULTS

The findings of the study are divided into two major categories for presentation. The first

category explains the socio-personality traits of the respondents. Based on the demographics of

the respondents contacted for this study, this category describes the respondents' gender, level of

education, and work experience. The results of each objective related to the PPP's roles in

ensuring the availability of necessary medications in Ubungo Municipal Council healthcare

facilities are explained in the second category.

3.1 Demographic characteristics of respondents

The study intended to seek the opinions of respondents from different socio-cultural

backgrounds. However, gender, level of education, and work experience were assessed in this

study as shown in the figure below:

Figure 3.1: Demographic characteristics of respondents

Variables Quantities Percentage (%)

Gender
Males 43 60.91
Female 67 39.09
Level of Education
University/College Education 110 100
Job Experience of Respondents    
Below 1 year 6 5.45
1-2 years 43 39.1
2-4 years 32 29.09
5-6 years 9 8.18
Over 6 years 20 18.18

The study found that females constituted 60.91% of all respondents, while males constituted the

remaining 39.09% of all respondents. The study also found that 100% of respondents, facility in-

charges, pharmacy dispensers, and store in-charges, have a university or college education.

Further to that, the results showed that 39.09% of the respondents have job experience of 1-2

years, 29.09% have experience of 3–4 years, 8.18% have experience of 5–6 years, 5.45% have

experience of below 1 year, and the remaining 18.18% have job experience of over 6 years.

3.2 Findings

Based on the study's specific goals, which included determining the impact of PPP guidelines on

the availability of essential medicines in health facilities at Ubungo Municipal Council,

identifying the impact of PPP awareness on the availability of essential medicines in health

facilities at Ubungo Municipal Council, and investigating the effects of PPP implementation on

the availability of essential medicines were analyzed.

Inferential statistics were used to show the relationship between multiple variables and make

predictions. For purposes of analysis, Pearson correlation and regression analysis were used in

testing the hypothesis.

H0: Inclusion of PPP guidelines, PPP awareness and PPP implementation ensures the availability

of essential medicines and health facilities in Ubungo Municipal.

H0: [PPPg ᴧ PPPa ᴧ PPPi] → AEM

Whereas;

- PPPg is an independent variable representing PPP Guideline

- PPPa is an independent variable representing PPP Awareness

- PPPi an independent variable representing PPP Implementation

- AEM is a dependent variable representing Availability of Essential Medicines

To test the composite hypothesis H0: [PPPg ᴧ PPPa ᴧ PPPi] → AEM, each independent variable

was tested separately (for example H1: PPPg → AEM). since the questionnaires used a Likert

Scale, Microsoft excel was used to analyse data for the inferential analysis.
3.2.1 PPP guidelines and the availability of essential medicine

The coefficient analysis of factors used to determine the role of PPP guidelines and the

availability of essential medicine in health facilities at Ubungo Municipal Council shows a

strong positive correlation of 0.598 with variability of 24.8% as shown in table 3.1 below.

Table 3.1: Statistical Results and Correlation Matrix for the role of PPP guidelines and the
availability of essential medicine.

Role of PPP Guideline on availability of 1 2 3 4 5 r r2

essential medicines: PPPg→ AEM

Purchasing guidelines are well articulated 3 1 2 2 4 0.1769 3.5%

Purchasing guidelines are relevant 1 2 2 1 4 0.3796 14.4%
Distribution guidelines are well established 0 3 0 2 0 0.277 7.5%
Distribution ensures availability 3 3 2 0 7 0.1869 3.5%
Storage guidelines are well established 1 1 9 3 3 0.307 15.3%
Storage guidelines ensures supply 8 13 2 2 2 0.399 9.6%

Total Response 16 23 9 10 20
Average Response 0.6 4.8 21.4 20 3.3
Percentage of Response 1.3% 9.5% 42.8 40% 6.5%
%
Coefficient of Correlation (r) 0.598
Coefficient of Determination (r2) 24.8%

Furthermore, table 3.1 shows that there is a weak positive correlation between articulations of

purchasing guidelines to the availability of essential medicines as it was represented by the

coefficient of correlation of 0.1769 and variability of 3.5%. Additionally, a correlation of 0.3796

and a variability of 14.4% show a weak positive relationship between the relevance of

purchasing guidelines and to availability of essential medicine. In comparison, the correlation of

0.277 and variability of 7.5% depicts a weak positive relationship between the establishment of

distribution guidelines and the availability of essential medicines.

3.2.2 PPP awareness and the availability of essential medicine

The coefficient analysis of factors used to assess the influence of PPP awareness and the

availability of essential medicine in health facilities at Ubungo Municipal Council shows a

strong positive correlation of 0.567 with a variability of 25.6% as shown in table 3.2 below.

Table 3.2: Statistical Results and Correlation Matrix for the influence of PPP awareness
and the availability of essential medicine

Influence of PPP awareness on the availability 1 2 3 4 r r2

of essential medicines: PPPa→ AEM

Enough training 11 12 2 3 0.845 68.5%

Employees are well informed 2 7 2 2 0.3696 16.4%
Information is well disseminated 1 4 2 3 0.3471 15.2%
Transparency is adhered 3 5 2 4 0.1769 3.5%

Total Response 18 28 8 12
Average Response 4.3 2.8 9.8 6.5
Percentage of Response 10% 49% 6% 49%
Coefficient of Correlation (r)

Coefficient of Determination (r2)

Additionally, table 3.2 shows that the found that there is strong positive correlation between

enough training to the availability of essential medicines as it was represented by the coefficient

of correlation of 0.845 and variability of 68.5%. Additionally, a correlation of 0.3696 and a

variability of 16.4% show a weak positive relationship between informed employees and the

availability of essential medicine. In comparison, the correlation of 0.3471 and variability of

15.2% depicts a weak positive relationship between information dissemination and availability of

essential medicines.
3.2.3 PPP implementation and the availability of essential medicine

The coefficient analysis of factors used to determine the role of PPP guidelines and the

availability of essential medicine in health facilities at Ubungo Municipal Council shows a

strong positive correlation of 0.628 with a variability of 39.4% as shown in table 3.3 below.

Table 3.3: Statistical Results and Correlation Matrix for the effects of PPP implementation

and the availability of essential medicine

Effects of PPP implementation on availability of 1 2 3 4 5 r r2

essential medicines: PPPi→ AEM

PPP is effectively implemented 1 4 2 3 4 0.3761 14.1%

Adequately monitored 1 7 2 2 4 0.3796 14.4%
Feedback provided 11 2 6 2 3 0.810 65.6%
Regularly reviewed 3 8 2 4 7 0.1869 3.5%

Total Response 16 21 12 11 18
Average Response 2 8.6 20.5 16.6 2.3
Percentage of Response 7% 30% 14% 21% 28%
Coefficient of Correlation (r) 0.628
Coefficient of Determination (r2) 39.4%

Furthermore, table 3.3 shows that there is a weak positive correlation between the effective

implementation of PPP to the availability of essential medicines as it was represented by the

coefficient of correlation of 0.3761 and variability of 14.1%. Additionally, a correlation of

0.3796 and a variability of 14.4% shows a weak positive relationship between adequate

monitoring to the availability of essential medicine a correlation of 0.810 and a variability of

65.6% depicts a strong positive relationship between the provision of feedback and to availability

of essential medicines.
3.4 Summary of the Findings: Testing the Composite Hypothesis

H0: [PPPg ᴧ PPPa ᴧ PPPi] → AEM

There is a strong positive relationship between PPP guidelines, PPP awareness and PPP

implementations to the availability of essential medicines in health facilities in Ubungo

Municipal Council with a coefficient of correlation of 0.5523 when all the independent variables

are combined, as shown in Table 3.4 and variability of 30.5%. When all worked together, the

three conventional variables (PPP guidelines, PPP awareness and PPP implementation) will

ensure the availability of essential medicines in health facilities.

Table 3.4: Statistical Results and Correlation Matrix for Combined Variables

H0: [PPPg ᴧ PPPa ᴧ PPPi] → AEM 1 2 3 4 5 r r2

PPP guideline 2 8.6 20.5 16.6 2.3 0.506 25.6%

PPP awareness 0.6 4.8 21.4 20 3.3 0.498 24.8%
PPP implementation 1.3 9.5 21 16.1 2.1 0.628 39.4%

Total Response 4.9 30.4 84.9 91 39

Average Response 0.98 6.08 16.98 18.2 7.8
Percentage of Response 2% 12% 34% 36% 16%
Coefficient of Correlation (r) 0.5523

Coefficient of Determination (r2) 30.5%

4. DISCUSSIONS

Ensuring adherence to contractual obligations and the efficient provision of healthcare services is

crucial for privately-run healthcare facilities operating under public-private partnership (PPP)

arrangements. To achieve this, it is necessary to closely monitor and evaluate these PPP

initiatives' activities, as mandated by the Tanzanian National Public-Private Partnership Policy of

2009 [12]. According to this policy, the government, in collaboration with the private sector, is
responsible for (i) establishing a monitoring and evaluation framework that includes performance

indicators and benchmarks, (ii) defining a specific timeline for conducting evaluations, and (iii)

periodically reviewing the policy and associated legislation as necessary. However, it has been

observed that the monitoring and evaluation of PPP implementation needs to meet the

requirements and indicators outlined in the policy. Other researchers have also acknowledged

this inadequacy [13, 14], who have highlighted similar challenges.

According to Raman and Bjorkman [13], the issue of inadequate monitoring and evaluation of

PPP in the healthcare sector can be attributed to insufficient attention given to performance

indicators. Basu [12] further argues that the problem is exacerbated by the government's limited

capacity to monitor and evaluate the private sector effectively. These observations suggest that

the enforcement procedures may be weak and accountability mechanisms may be lacking,

leading to a reluctance among partners to engage in PPP activities fully. Moreover, the presence

of poor monitoring and evaluation processes can indicate deficiencies in communication

structures and procedures. To address these challenges, Barnes [14] asserts that effective PPP

implementation requires the integration of a well-defined taxonomy of efficient communication.

This would assist practitioners in designing successful implementation plans and establishing

realistic expectations.

Conferring to a study conducted in Tanzania [14], it was discovered that despite supportive

policies in place, there needs to be more understanding and acknowledgement of the concept of

public-private partnerships (PPP) at the district level. This is accompanied by a reluctance to

collaborate with non-state actors and a general sense of mistrust towards the private sector.

Generally, in this specific PPP, the private supplier adhered better to contractual terms than the

public sector districts. Various studies have documented similar findings, particularly in
developing countries like Ghana, Zimbabwe, and Kenya [12, 15]. A well-designed

communication plan can facilitate meaningful engagement and active participation, fostering the

necessary level of trust for the success of PPP initiatives. Effective communication also helps

overcome bureaucratic resistance, increasing transparency in managing PPP-related matters

within the healthcare sector [16]. By enabling a two-way dialogue on contentious issues,

communication can prevent the erosion of public confidence and trust.

The regulatory framework guiding PPP implementation sometimes grants more power to the

public sector. Mahoney and Thelen [17] highlight that institutional arrangements are crucial in

determining power dynamics, and influencing decision-making among partners. Existing power

dynamics between partners during PPP implementation can pose significant challenges when

each partner strives to maintain control. Belt and Spierenburg [18] caution that the distribution of

benefits or outcomes in PPP should align with power relations. Within a partnership, power can

be exercised through political or financial coercion in addition to authority and legitimacy [19].

In the case of Ubungo municipality, the government's power and authority have influenced

decision-making in implementing PPP plans. Private health facility owners have needed more

autonomy in making decisions regarding the partnership while delivering healthcare services in

the municipality. The current institutional arrangement for PPP in Ubungo reflects the

observation made by Buse and Harmer [19] that central and local governments hold more

decision-making power at the expense of private health facility owners. It is important to note

that the existing power relations have yet to result in a neutral mechanism that promotes a win-

win situation for all partners involved. Sevilla [20] emphasizes that the specific structure of PPP

in any given context is shaped by the policy and regulatory framework, which often requires

adjustments to accommodate newinstitutional arrangements, partnerships, and collaborations.

5. CONCLUSIONS

The study discovered a significant positive relationship between PPP guidelines, PPP awareness,

and PPP implementations and the availability of essential medicines in healthcare facilities in

Ubungo Municipal Council, with a coefficient of correlation of 0.5523 and a variability of 30.5%

when all independent variables are combined. The availability of essential medications in

healthcare facilities will therefore be ensured by three conventional variables (PPP guidelines,

PPP awareness, and PPP implementation) when they are all combined.

5.1 Policy and Programmatic Recommendations

Based on the results of the stud. the following are recommended;

i. To provide essential medicines, the government should create and implement clear

regulations that define the roles and responsibilities of all parties involved in PPPs. This

will guarantee that PPPs are appropriately structured and managed.

ii. The government should provide more funding to public health facilities so they can

purchase necessary medications. The sustainability of PPPs will increase if there is a

sufficient supply of essential medications in healthcare facilities, easing the burden on the

private sector. The government should actively promote public-private partnerships for

the provision of essential medicines. This can be done by creating a favorable policy

environment that encourages private sector investment in providing essential medicines

and incentivizing private sector partners.

iii. The government should strengthen the supply chain management system for essential

medicines to ensure an uninterrupted supply to health facilities. This will require

 developing robust logistics systems, including warehousing and distribution networks,

and adopting appropriate technology to track and monitor essential medicines.

iv. The government should ensure that essential medicines supplied through PPPs meet

quality standards and are subject to rigorous quality control and assurance measures. This

will require establishing effective regulatory systems, including regular inspections and

testing of essential medicines and developing clear quality control standards.

v. The government should invest in building the capacity of public sector officials and

private sector partners to manage and sustain PPPs to provide essential medicines

effectively. This can be done through training programs, mentorship and coaching, and

the provision of technical assistance.

vi. The government should establish a monitoring and evaluation system to track the

performance of PPPs in the provision of essential medicines. This will help identify

improvement areas and ensure that PPPs meet their objectives.

5.2 Study limitations

The study had the following limitations;

i. We have a limited geographical scope in essence, the study had a limited geographic

area, which could affect the generalizability of the findings to other regions or countries.
 ii. Reliance on self-reporting through which the study relied on self-reported data from

health facility staff, which could be subject to bias and may not accurately reflect the

actual availability of essential medicines.

iii. External factors, such as supply chain disruptions essential medicines' availability and,

confound the study's results the study.

iv. The study was limited in terms of its timeframe, it may not capture the longer-term

effects of PPP on the availability of el medicines.

5.3 Implications for Future Research

Should focus on the following;

i. Future research could use a larger sample size to increase the generalizability of the

results.

ii. Longitudinal studies could be conducted to in more extended to assess the effects of PPP

on the availability of essential medicines over a longer period.

iii. Comparative studies could be conducted to compare the effectiveness of PPP with other

interventions to improve access to essential medicines.

iv. Intervention studies could be conducted to determine the most effective PPP strategies for

improving the availability of essential medicines in health facilities.

v. Future research could evaluate specific PPP models or partnerships to identify the most

effective approaches for improving the availability of essential medicines.

vi. Future research could explore external factors that may affect the availability of essential

medicines, such as supply chain disruptions or political instability, to understand their

impact on PPP interventions' better effects.

vii. Future research could evaluate the long-term effects of PPP interventions on the

availability of essential medicines to determine their sustainability and potential for

scalability.
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