The functionality of health facility governing committees and their associated factors in selected primary health facilities implementing direct health facility financing in Tanzania: A mixed‐method study

Abstract Background In Lower and Middle‐Income Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF). Methods To collect both qualitative and quantitative data, a cross‐sectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, in‐depth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research. Result HFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187. Conclusion The study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.


Decentralization initiatives in Lower and Middle-Income Countries
(LMICs) allowed communities to participate in governing and administering PHC delivery. Community governance structures known as Health Facility Governing Committees (HFGCs) were created to govern Decentralization initiatives in LMICs allowing communities to participate in governing and administering PHC delivery. Community governance institutions called HFGCs were created to represent communities in the governance and management of PHC facilities. [5][6][7] The newly formed HFGCs are assigned specific responsibilities and powers in the administration of primary healthcare facilities. 8,9 Following that, LMICs have continued to pursue reforms such as fiscal decentralization to empower and strengthen community engagement, or the use of HFGCs to improve health service delivery at PHC institutions. 10 It is considered that the more empowered and autonomous HFGCs are, the more likely they are to carry out their delegated obligations, hence improving the health system's responsiveness to community needs and preferences. 6,11 Therefore, HFGC's functionality in this context entails the ability of the HFGCs to accomplish their assigned functions or duties and responsibilities.
In theory, decentralizing governance and control of health service delivery to user committees such as HFGCs improve service delivery and establish a link between healthcare professionals and communities. 8,12 However empirical studies suggest that achieving enhanced users committee's participation in governing and managing health service delivery can be very complex. 13 Several issues related to the complexity of having effective and functional user committees or HFGCs in PHC institutions have been identified in the literature.
Country context and nature of decentralization undertaken by each county are some of the cited reasons for ineffective HFGCs in PHC. 13,14 For instance, Abimbola et al. 15 in Nigeria HFGCs were found to be underperforming in their roles because some members were unaware of their responsibilities and had the insufficient financial capacity and ability to manage facility resources. Ved et al. 16 suggest that in India community participation through village health, sanitation and nutrition committees are not functional because they are not aligned with decentralized government. To unlock the HFGCs functionality gaps, the literature suggests the implementation of full decentralization (fiscal, political, and administrative) at PHC facilities. [17][18][19] This stems from the fact that fiscal and political decentralization provides an atmosphere in which HFGCs can use their powers and fulfill their mandates. This is reinforced by the empowerment framework, which says that an agency and opportunity structure influences an individual's or group's ability to make effective decisions. The ability of an individual or group, such as HFGC, to make a meaningful decision that is influenced by their age, material ownership, abilities, experience, and educational level is referred to as agency. Opportunity structure refers to the formal or informal setting in which individuals or groups function, such as fiscal decentralization, which is determined by norms, the availability of funding, availability rules, and regulations. 20,21 Currently, some LMICs are implementing fiscal decentralization through various arrangements in primary health facilities among other things to empower and improve HFGCs' functionality.
In Tanzania, HFGCs were established in 1999 as part of Health Sector Reforms to increase community involvement in the administration and management of PHC facilities. 22 These HFGCs are made up of members of the community who are either elected or appointed by their peers, civil society, and private health providers. The following functions are delegated from these HFGCs: Participate in the development of facility plans and budgets for the management of facility income, expenditures, and performance. Similarly, to gather funds for construction and maintenance management. Furthermore, discussing and addressing the community's concerns, as well as rallying the community to participate in the improved Health Community Fund. 22,23 However, before 2018, empirical evidence suggests that HFGCs performed poorly in carrying out their duties. 24,25 For instance, Maluka et al. 26 and Kamuzora et al. 27 found that implementation of decentralization in the district was offering only a tiny number of local elites, particularly medical professionals, were offered powers and were are allowed to participate in decision making, leaving community people and other stakeholders powerless. In other research from Tanzania, low funding, a lack of fiscal autonomy, late transfer of funds to the facility, and a lack of community participation in planning were identified as impediments to decentralization at PHC facilities. 24,[28][29][30] To address these issues, Tanzania's government implemented Direct Health Facility Financing (DHFF) to increase fiscal decentralization at PHC facilities and allow more community/HFGC and service providers to participate in the governance and management of their health facilities at the facility level.  HFGCs and the DHFF context, as well as its impact on HFGC functionality. Figure 1 implies that the functionality of HFGCs is determined by the qualities of its members, such as their education level, experience, occupation, leadership, selection, and composition.
The fiscal decentralization context (DHFF) in which HFGCs operate creates a favorable setting for them to carry out their delegated tasks. The DHFF is expected to empower HFGCs by providing prompt access to funding, standards for using finance, and training for HFGCs on their roles and financial management. In addition, the DHFF framework is intended to explain HFGC's powers and mandates as they carry out their tasks and obligations. As a result of the DHFF empowerment, the HFGC's ability to carry out its responsibilities will be enhanced, and health service delivery at their facilities will improve.

| METHODS AND MATERIALS
A cross-sectional design was employed in which both qualitative and quantitative data were collected simultaneously. The study was conducted between February and May 2021 in all four regions.

| Sample size and sampling procedure
This study used a total sample size of 280 respondents. The sample size for this investigation was determined using a four-stage multistage cluster sampling process. Because the study encompassed geographically separated areas and face-to-face data collection was essential, multistage cluster sampling was used. The sample criteria were based on the Ministry of Reginal Administration and Local Government's Star Rating Assessment of all primary health facilities in Tanzania, which was completed in early 2018. Tanzania's government implemented a star rating system to assess the performance of PHC facilities, including the functionality of HFGCs.
The assessed primary health facilities and their HFGC were ranked to determine the low and high-performing health facilities and HFGCs. 34 Star rating assessment of 2017/18 has been taken as a baseline because it is in the same year DHFF was introduced 6,35 (Table 1)

| Qualitative data collection
In-depth interviews with HFGC chairpersons and FGDs involving all selected HFGC members were used to collect qualitative data. Before beginning data collecting, research assistants received training on the interview and focus group guides. Before heading to the study region, the qualitative data collection tools were tested. The interview outline included 21 questions about HFGC's functionality and

| Quantitative analysis
The statistical program Statistical Product and Service Solution was used for the analysis (version 25). At a 5% level of significance, all statistical tests were determined. Data were analyzed using descriptive and inferential statistics, and the sample and participant characteristics were described using frequency tables and bar graphs. A binary logistic regression model was employed to determine characteristics associated with HFGC functionality because the outcome variable was dichotomized (0 = poor function, 1 = good function). 39 The general multiple logistic regression models are given as: Where, π x ( ) is the likelihood of HFGC functionality is "good function", indicates that the likelihood of having good functionality for participants at a given level of the independent variable is greater than that for the reference category. Similarly, an estimate of OR <1 specifies that the chance of being having good functionality at a given level of the independent variable is less than that for the reference category.

| Variables of the study
The dependent variable for this study was the functionality of HFGC.
The Functionality of HFGCs in primary health facilities implementing DHFF was statistically analyzed based on the experience of HFGC members in accomplishing their assigned functions as indicated in the 4 points Likert Scale in which each point was in percentage. Then, the 4 points Likert scales were dichotomized for further analysis. The first two points namely "Very Low" and "Low" were coded 0 and "High" and "Very High" were coded 1. the score of functionalities was calculated by summing up all dichotomized variables. The possible minimum score was 0 and the possible maximum score was 9.
The functionality score was categorized into two categories those who scored above the median (5) were regarded as good functioning while those who scored 5 or less were regarded as poor functioning. This practice is consistent with the analysis conducted in the study of health system responsiveness conducted in Tanzania. 23 The independent variables for this study included nine (9) items (functions) which determined the functionality of HFGCs as indicated in Table 3.

| Qualitative analysis
A total of 14 in-depth interviews and focus groups were recorded, verbatim transcribed, and anonymised for analysis. The theme framework was employed as the theoretical framework to assess the data of HFGCs after data collection based on topic areas. The material was classified independently by four researcher assistants, and the researcher then analyzed the coded content, subcategories, and categories to determine critical conclusions. As a result, the statement referring to HFGC members' participation in various HFGC functions was studied to determine the functionality of HFGCs and to determine if the empowerment framework's argument was applicable or not.

| Reliability
Many aspects of interest in the social sciences and other professions, such as anxiety or job satisfaction, are difficult to quantify. We ask a number of questions and integrate the answers into a single numerical value in such circumstances. When things are utilized to make a scale, however, they must be internally consistent.
Cronbach's alpha was used in this study to assess our instrument's internal consistency and reliability. It assesses how well a set of variables or items accurately reflects a single, one-dimensional latent feature of people. Cronbach's alpha values vary from 0 to 1, with values greater than 0.7 indicating adequate internal reliability. Table 3 presents       Table 5). Participants also discussed the difficulties that many communities face in recruiting community members to join CHF. Despite their commitment to this function, FDG comments indicated that the number of community members joining the upgraded community health fund is not promising in comparison to the efforts made.

| The autonomy and powers of HFGCs
"The challenge we encounter now is the number of community members joining the CHF is very low compared to the efforts we have put in sensitizing the community about the importance of being a member of CHF.

| Participation in planning and budgeting process
In the implementation of the DHFF, it was discovered that HFGC engagement in planning and budgeting is high. Participants believed that under the DHFF, they no longer had to wait for council-level planning to be completed. They revealed that they have been actively participating in the planning process through HFGC meetings, with certain members also participating through the planning committee. Participants in the focus groups described their involvement in many functions, including financial roles. The following was said by one of the FGD members. ……when the health facility in-charge wants to buy anything she informs us as committees, therefore we revisit our health plan and budget to see if such an item was planned to be procured…. All authors have read and agreed to the final version of the manuscript.

ACKNOWLEDGMENT
The authors thank all the participants of this study.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
All data generated or analysed during this study are included in this published article and Supporting Information File.

TRANSPARENCY STATEMENT
We confirm that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.