Unlocking value: a comprehensive costing study of Primary Health Care service delivery in Tanzania 

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However, greater, and more effective investments are needed to expand access to quality PHC services and further improve population health outcomes. Furthermore, as Tanzania graduated to lower-middle-income country status, the Government is expected to move towards full domestic financing of health services. To support this aim, there is a need to estimate the current expenditure of PHC services, the resources needed to deliver quality PHC services according to nationally defined standards, and the gap between the two. Methods: A top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included. The total funding gap was calculated as the difference between actual expenditure and estimated normative cost. The gap analysis was undertaken by input categories and level of facility. Results: Government expenditure on PHC substantially increased between fiscal year (FY) 2021/22 and 2022/23. Nevertheless, the spending level is significantly lower than global benchmarks, and the resources required to deliver quality PHC services according to the basic service standards. Moreover, the analysis revealed there are important differences in the levels of spending per capita across regions and health service delivery productivity. Conclusions: The Government of Tanzania’s PHC spending increased significantly over the two years, raising the per capita PHC expenditure and the expenditure per outpatient visit. As the Government of Tanzania increasingly finances health services from domestic sources, a key consideration for long-term planning in the context of declining partner funding is the total amount of funding required to provide quality PHC services equitably to the population. At the same time, a more detailed understanding of current PHC expenditure informs the calculation and estimation of the funding gap. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Background Tanzania has made significant strides in improving the health of its population over the last two decades. The neo-natal mortality ratio declined from 112 deaths per 1,000 live births (LBs) in 2004-2005 to 43 deaths per 1,000 LBs in 2022; similarly, infant mortality halved, dropping from 68 to 33 deaths per 1,000 LBs during the same period, and skilled attendance during delivery increased from 47% in 2004-2005 to 85% in 2022 (1) (2). These enhancements stemmed from an expansion in the number of health facilities, improved medicines availability, greater domestic funding, and the strengthening of governance by implementing decentralisation by devolution (3). However, further progress is needed to improve health outcomes and achieve the Sustainable Development Goals. Tanzania remains heavily reliant on donor funding for health service delivery. Such funding is highly fragmented with only a fraction of the resources directed through the Health Basket Fund, the health sector’s on-budget donor funding pooling mechanism. Foreign-funded projects that are implemented through government authorities are reported by the Accounting Officers through the Direct to Project Funds Modality (D-Funds) and do not appear on the Medium-Term Expenditure Framework. Private expenditure on healthcare is also high, representing 27% of the current health expenditure in 2022 (4). Out-of-pocket expenditures account for the largest share (26%) of private expenditures in the form of user fees collected and retained at the health facility level (5). Tanzania has long prioritized PHC as the pathway to achieving universal health coverage (6). Nevertheless, greater, and better investments are needed to expand access to quality PHC services and further improve population health outcomes. As Tanzania graduated to lower-middle-income country status in 2020, the government is expected to incrementally increase domestic financing of health services. To support this aim, there is a need to estimate the current expenditure of PHC service, the resources needed to deliver quality PHC services according to Government-defined standards, and the gap between the two. Several studies have been conducted on the Tanzania mainland to estimate the costs of delivering individual health interventions (7) (8). However, no comprehensive costing exercise has been recently conducted to estimate government expenditure on PHC service delivery and the gap vis à vis the resources needed to deliver quality PHC services. To address this information gap, the President’s Office Regional Administration and Local Government (PORALG) and the Ministry of Health (MoH) partnered with UNICEF to undertake a comprehensive PHC costing exercise. The study aimed to generate estimates to inform domestic resource allocation for the equitable delivery of quality PHC services. Methods Study Setting In Tanzania, the public health sector is divided between the central and local government, encompassing both the ministerial and the regional administration tier. The MoH leads health policy development and implementation. At the sub-national level, the Tanzania mainland is divided into 25 regions that are an administrative extension of the central government. The local government is divided into 184 Local Government Authorities (LGA) responsible for decentralised public services delivery, including health, and report to the PORALG (9). In mainland Tanzania, PHC services are delivered through a multi-layered system. This comprises over 6,000 public dispensaries, health centers, and district hospitals, offering a comprehensive approach to health encompassing promotion, prevention, treatment, rehabilitation, and palliative care. A detailed description of the services provided at the different levels is contained in various policy documents (10) (11), but a summary of responsibilities is as follows: At the community level, health workers engage in health promotion and prevention activities in neighbourhoods and villages. The village level provides preventive and curative outpatient services through dispensaries serving between 6,000 and 10,000 people. Clinical assistants and enrolled nurses supervise dispensaries. The ward level serves as the referral point for the village level, with health centers offering more extensive services, including inpatient care. Health centers are led by clinical officers, supported by enrolled nurses, and serve approximately 50,000 people. District hospitals represent the next level, providing specialised medical care and functioning as teaching hospitals for medical, paramedical, and nursing training. District hospitals employ medical doctors and nursing officers and cater to the district population, which varies significantly by district. Multiple districts are clustered into zones, each of which has a regional hospital, and at the top of the pyramid are specialised hospitals overseen by the MoH. Scope of the costing exercise The overarching aim of this study was to develop national estimates of the total financial costs for the full package of PHC services. The study had three specific objectives. First, to understand the expenditure incurred by the government to deliver PHC services (i.e. actual costs) in FY 2021/22 and 2022/23; secondly to estimate the total resources needed to deliver quality PHC services as per the Basic Health Service Standards (i.e. normative costs); and finally, to calculate the gap between actual costs and the normative costs. The costing assumed a provider’s perspective and estimated the expenditure incurred by the government to provide health services in public health facilities. As a first step, actual total expenditure was estimated for PHC service delivery by the level of the facility. The second step consisted of the estimation of total resources needed, using normative costing, to provide PHC services. The final step involved the calculation of the resource gap between the actual cost of providing PHC services and the estimated total resource need. Scenarios for Costing The cost of PHC service delivery was estimated for two different scenarios: the current scenario using actual expenditure in FY 2021/22 and 2022/23, and the normative scenario. In the Actual Expenditure Scenario , the actual government expenditure incurred in PHC facilities was used to indicate the total expenditure incurred by the government to provide PHC services. The Normative Scenario considered the resource requirement for service delivery using the 2017 Basic Service Standards, fully implemented, at all PHC levels without any adjustment. The difference between the current and the normative scenarios allowed for the estimate of the total resource gap across the different levels of service delivery and service delivery inputs. Costing Approach A top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included. Costs incurred at the regional and national levels (e.g. supportive supervision), and by off-budget development partners to support PHC services were excluded from the analysis. Approach for estimating costs under the actual expenditure scenario All facility and community-level expenditures incurred by the government in dispensaries, health centers, and district hospitals on human resources, medicines, medical supplies, and facility operations in FY 2021/22 and 2022/23 were collected and included. Approach for estimating costs under the normative scenario The resources needed for human resources (HR) were estimated using facilities as the unit of analysis. The number of HR in the staff establishment of the Basic Health Services Standards was multiplied by the government remuneration by cadre. The total normative HR cost per facility was a summation of the total computed remuneration of all cadres, and the total normative HR cost for PHC services per level of facility was obtained by multiplying all government facilities of that level by the HR cost of a standard facility. The country’s normative HR cost comprised the summation across all the facility types. The cost of health commodities was based on the current estimated requirements by facilities, captured in the national quantification, supplemented by the programme quantifications for HIV, malaria, tuberculosis, and leprosy. The national quantification for essential medicines was adjusted to reflect the reported underestimation by 28% in FY 2021/22 and 26% in FY 2022/23. Normative operational costs were assumed to be equal to the actual expenditure on operations incurred by the facilities. Data sources The study relied on secondary data generated largely through government routine systems. The normative costing entailed estimating the cost of HR using the Basic Health Services Standards. HR costs were added to the health commodities resource requirements obtained from the national quantification reports for FY 2021/22 and 2022/23 and operation costs from the Facility Financing and Accounting Reporting System (FFARS). The data sources consisted of FFARS for facility expenditure, PlanRep for HR expenditure incurred directly by the Ministry of Finance (MoF), the Medical Stores Department (MSD) for health commodities procured and supplied through government funding, and the District Health Information Softeward 2 (DHIS2) for service utilisation. Relevant stakeholders were consulted in their professional capacity to assess the accuracy of the national quantification of health commodities and appropriate adjustments made. Table 1 provides an overview of the different types of data, sources, and uses of the data. Table 1 Data type, sources, and uses of the data Data type Sources Uses of the data Expenditure by facility type (HR, health commodities, facility operations) FFARS Actual expenditure on medicines, supplies, operating costs, and HR directly procured by the facility. Expenditure on medicines and supplies MSD reports and FFARS Estimate actual expenditure on commodities incurred via MSD and procurement from private vendors by facilities. Personnel emoluments PlanRep Budget values as proxy for expenditure on centrally remunerated staff, which was not included in FFARS for PHC facilities Normative estimate for personnel emolument Basic Health Service Standards Guides the analysis of total HR needs at facilities to underpin the normative costing Normative estimate of medical supplies, reagents, medical equipment and pharmaceuticals National quantification report, vertical programme quantification for ARVs and malaria Used to estimate the normative value of health commodities and supplies Capital expenditure for future facility development and infrastructure expansion Number of health facilities registered on FFARS Supports estimates for capital development costs and other capital expenditure Data analysis The costing was undertaken using Excel-based analysis tools. Estimates were compiled for individual cost inputs (i.e. HR, health commodities, and facility operating costs) by region and by level of facility (i.e. dispensary, health centre, and district hospital) and aggregated to generate national and regional estimates. In addition, high-level unit costs were calculated for outpatient equivalent visits for each region and nationally. In-patient days were adjusted by a factor of four to convert them to outpatient equivalent days. All estimates were converted to USD using the exchange rate of 1 USD = 2,298 TZS for FY 2021/22 and 1 USD = 2,310 TZS for FY 2022/23 (Bank of Tanzania average mean exchange rate). Quality assurance and validation The data obtained from the described sources were triangulated with others (e.g. the National Health Accounts) and other costing studies employing different methodologies to assess their quality and identify anomalies. The cost calculations and analysis spreadsheets were also checked for accuracy, completeness, and reasonableness. Representatives from the PORALG Health, Social Welfare, and Nutrition Services Directorate, the MoH, the MoF, UNICEF, and other development partners validated data and outputs during a technical review session. Ethical approval Ethical approval was initially granted by the National Institute for Medical Research in Tanzania on October 7 th , 2021, with reference number NIMRHQR8a/ Vol/IX / 3797. Subsequently, a protocol amendment was approved on January 25 th , 2024. Results Health facility service utilization In FY 2021/22 and FY 2022/23 there were 5,719 and 6,042 government-owned PHC facilities across Tanzania mainland. Over the two years, 61,302,737 and 39,008,713 outpatient visits were provided, as well as 619,614 and 659,005 inpatient visits ( Figure 1 , Figure 2 ). The significant reduction in the number of outpatient visits could be explained in relation to data reporting challenges. Actual Government spending on PHC The study found that total expenditure on PHC from the central government, the National Health Insurance Fund, the Community Health Fund, the Health Basket Fund, and other on-budget donors grew from TZS 801 billion (USD 349 million) to TZS 1,158 billion (USD 501 million) between FY 2021/22 and FY 2022/23 ( Figure 3 ). The significant growth is attributed to the rise in the expenditure on HR due to the increase in the health personnel employed, mostly at the level of district hospitals, in FY 2022/23, and the growth in facility operating costs resulting from the operationalisation and upgrade of 310 health facilities. Expenditure on health commodities, comprising pharmaceuticals, reagents, and equipment, marginally decreased between the two years, especially in dispensaries. No reasons were attributed to this beyond those related to the operationalisation and upgrade of 310 health facilities. While total per capita expenditure on PHC increased from TZS 12,891 (USD 5.61) to TZS 18,215 (USD 7.89) between the two years, implying a more than proportional increase compared to the population growth, it remained significantly lower than the WHO recurrent PHC benchmark of TZS 136,900 (USD 59) (12). The analysis of government expenditure in PHC at the regional level also revealed significant disparities. The lowest government expenditure on PHC was reported in Simiyu and was less than a third of the expenditure in Njombe, the region with the highest level of government spending ( Figure 4 ). Expenditure per standard unit of output, measured using outpatient visits, nearly doubled in all regions between FY 2021/22 and FY 2022/23. This finding suggests that despite increased expenditure on PHC, there was no significant improvement in health service access. Normative costing for PHC The normative costing revealed that TZS 4,519 billion (USD 1,966 million) and TZS 6,384 billion (USD 2,997 million) are needed to deliver quality PHC services according to the national Basic Health Services Standards. The sharp increase between the two years was primarily driven by the health commodity needs which grew due in response to the increased number of health facilities. The greater growth in commodity needs was reported at the dispensary level, followed by district hospitals. The analysis reveals that normative HR costs rose with the increase in registered facilities. The increase in HR needs between FY 2021/22 and FY 2022/23 was 10%, 10%, and 7% for dispensaries, health centres, and district hospitals, respectively ( Figure 5 ). The estimate of normative per capita cost shows that if the Government of Tanzania aligned its investment in PHC to the FY 2023/24 normative estimate of TZS 50,797 per capita, it would move towards achieving the WHO target of per capita PHC recurrent expenditure of TZS 136,900 (USD 59) (12). Funding gap analysis The gap analysis revealed that in FY 2021/22 and FY 2022/23, there was an 84% and 83% government funding gap for the delivery of quality PHC services, estimated as the difference between the normative costs and the sum of central government, Community Health Fund, and National Health Insurance Fund contributions. Due to the contributions of development partners and individuals paying for services out-of-pocket, the actual gap is likely lower than this estimate but remains significant ( Figure 6 ) . While district hospitals had the highest proportional funding gap in FY 2021/22, dispensaries accounted for 49% of the total funding gap in FY 2022/23. This change in proportions can be attributed to the increased number of facilities and the disproportionate increase in the commodity and staffing costs in FY 2022/23 in dispensaries ( Table 2 ). Table 2 Funding gap analysis by level of service delivery Level FY 2021/22 FY 2022/23 Actual Normative Funding gap Actual Normative Funding gap Dispensary 287 847 560 394 1,141 747 Health Centre 171 357 186 260 535 275 Hospital 255 526 271 409 887 478 Total 713 1,730 1,017 1,063 2,563 1,500 Relationship between spending, outputs, and outcomes Figures 7-9 show the relationship between current per capita expenditure for each region and skilled delivery, antenatal care (ANC) utilisation and mortality for children under-5 years for the same regions. A trend line has been included based on the observations. For the first two indicators, there is a clustering of regions in terms of per capita expenditure but significant variability in health indicator values. There seems little correlation between per capita expenditure and under-5 mortality. Notwithstanding that funding plays a critical role in increasing the availability of and access to health services, it should be noted that service utilisation for skilled delivery and ANC depends on many factors, including health-seeking behaviour. Under-five mortality depends on previous spending and other factors, and it may not be possible to draw conclusions from this analysis. Overall, the results show a positive relationship between government PHC per capita spending and service utilisation (skilled delivery and ANC 4+) and a weak, negative relationship with under-five mortality with high variability around the trend line. Nevertheless, these results underscore the important role of government financing in improving the welfare of its population. Discussion The study found that total per capita expenditure on PHC increased in the two years, implying a more than proportional increase compared to the population growth. However, expenditure remained significantly lower than the WHO per capita spending benchmark. The study also found high variation in expenditure and productivity across regions in Tanzania with implications for equitable access to PHC services. In-country variation may be partly attributed to the extent of donor off-budget support channelled to specific regions. Some inequity may be mitigated through such support, but further analysis is required to accurately assess the situation. Per capita health expenditure is an indicator that can be used to assess equity in funding health services across geographies and populations and is commonly reported in national costing and expenditure tracking. It is particularly helpful when it is combined with the burden of diseases in different regions. Relative benchmarking with other PHC systems within the region may also serve to highlight areas for improvement, recognizing that substantial variation exists in PHC models among countries. As noted very little work has been done to develop detailed definitions of what PHC encompasses making comparison difficult (12). The Primary Health Care Performance Initiative was designed to support the measurement of PHC-related variables, including PHC expenditure per capita as one recommended indicator with the understanding that PHC is the ‘cornerstone’ of sustainable development, and improvement is premised on better data and measurement (13). Costing studies are an important tool to reduce gaps in coverage of populations, services, and expenditures. They are particularly important sources of information in contexts of transition from donor to domestic financing. In Tanzania, there is no domestic resource mobilization strategy for the health sector and the government’s allocation lags that of most neighbouring countries in the region. While domestic healthcare financing has improved, resources have not kept pace with inflation and population demand. Given changing donor resource availability, coupled with Tanzania’s transition to lower middle-income status, more work is needed to identify effective financing mechanisms for the health sector. Increasingly costing studies of PHC services are available and can be used as ‘guide posts’ for investment and projected resource needs (12). The evidence generated by this study can be used to develop a robust advocacy strategy for more government and domestic resources for PHC services. Additionally, there is a need to reevaluate allocation to regions where the current PHC spending was indicative of unequal per capita expenditure, noting that it may not be possible to reduce historical allocations. Lastly, institutionalisation of the costing approach and related reporting is recommended so that MoH and PORALG can use it routinely to inform planning and ongoing management of health facilities. Limitations There were some limitations to the study. The data on direct payment for HR by the Central Government contained only personnel emoluments and did not capture allowances paid by the MoF. Therefore, the allowances were estimated based on the results of phase one of the costing study which include a sample of 70 facilities. The estimated need for commodities was taken from the quantification reports and adjusted for underestimation based on expert opinion and comparisons of estimates with actual expenditure. Additionally, there was a big difference between the estimated commodities needs for the two years which points to a forecasting and estimation process which is maturing and may contain inaccuracies. In theory, quantification starts as a process which considers prior year consumption and as such, may imbed inefficiencies and not be a true reflection of need. However, quantities for vertical programmes are based on the burden of disease and population coverage. The analysis also relied on service data reported from the DHIS2, which may be subject to completeness errors in reporting by health facilities. However, these data were used only for the estimation of cost per outpatient equivalent visit and do not impact on other reported results. Ideally, the analysis would consider a scenario that considers affordability and other constraints, referred to as a Feasible Scenario. This scenario would generate a total resource need below that generated by the normative costing and would adjust, for example, staff establishments for output and setting, which the Basic Health Services Standards do not go beyond the classification of the health facility. It was not possible to generate a Feasible Scenario due to the lack of reliable data to underpin assumptions. Conclusion The study shows that the central government plays a critical role in financing PHC in the country. The government’s PHC spending increased significantly over the two-year period, raising the per capita PHC expenditure and the expenditure per outpatient visit. The increase was largely attributable to the salaries of public servants and the increased numbers of staff employed by the government. Reaching WHO per capita spending benchmarks for lower-middle-income countries will nevertheless require significantly more sustainable domestic resources and investment. As the Government of Tanzania increasingly finances health services from domestic sources, a key consideration for long-term planning in the context of declining partner funding is the total amount of funding required to provide quality services equitably to the population. At the same time, a more detailed understanding of current PHC expenditure informs the calculation and estimation of the funding gap. Abbreviations ANC Antenatal care D-Funds Direct to Project Funds Modality DHIS2 District Health Information System FFARS Facility Financing and Accounting Reporting System FY Fiscal year HR Human resources LB Live births MOF Ministry of Finance MOH Ministry of Health MSD Medical Stores Department PHC primary health care PORALG President’s Office Regional Administration and Local Government TZS Tanzania Shillings USD United States Dollar Declarations Availability of data and materials: All data came from the Goverment financial systems. Competing interests: The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. Consent to publish declaration: not applicable. Ethics: Ethical approval was granted by the National Institute for Medical Research in Tanzania on October 7th, 2021, with reference number NIMRHQR8a/ Vol/IX / 3797. Subsequently, a protocol amendment was approved on January 25th, 2024. Funding: The funding was from the Swiss Agency for Development and Cooperation and Global Affairs Canada. Authors' contributions: Design of the study was done by FM, WCM, NK, JTK, DM, RK, CS. Acquisition and analysis for the study was done by FM and CS. Interpretation of findings was done by FM, WCM, NK, JTK, DM, RK and CS. The study was written by FM and CS with inputs from WCM, NK, JTK, DM, RK, GA and WE. The manuscript was written by FM and GA. All authors reviewed the manuscript. Acknowledgements: We wish to acknowledge the generous support provided by the Swiss Agency for Development and Cooperation as well as Global Affairs Canada. We further wish to acknowledge the Health Basket Fund partners and the Government of Tanzania for their feedback and contributions to this study and unwavering commitment to the delivery of primary healthcare for the people of Tanzania. References Ministry of Health (MoH) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2022. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report. Dodoma, Tanzania, and Rockville, Maryland, USA: MoH, NBS, OCGS, and ICF. National Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. Tanzania Demographic and Health Survey 2004-05. Dar es Salaam, Tanzania: National Bureau of Statistics and ORC Macro. United Republic of Tanzania, Ministry of Health, Community Development, Gender,, Elderly and Children. Health Sector Strategic Plan July 2021 – June 2026 (HSSP V) [Internet]. 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Basic Standards for Health Facilities: Dispensaries, Health Centres, Stand Alone Dental Cllinics and Rehabilitation Medicine Facilities (MoHCDGEC: Tanzania). Stenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S, Tan-Torres Edejer T. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study. Lancet Glob Health. 2019 Nov;7(11):e1500-e1510. doi: 10.1016/S2214-109X(19)30416-4. Epub 2019 Sep 26. PMID: 31564629; PMCID: PMC7024989. Veillard J, et al. Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection. Millbank Q. 2017;95(4). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 31 Jul, 2025 Reviews received at journal 24 Jul, 2025 Reviews received at journal 18 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers invited by journal 26 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Editor invited by journal 04 Jun, 2025 Submission checks completed at journal 04 Jun, 2025 First submitted to journal 04 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6309932","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":477753897,"identity":"4f6afca2-2183-4d32-b9c2-d7d7ba0052f1","order_by":0,"name":"Federica 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Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Dastan","middleName":"","lastName":"Mshana","suffix":""},{"id":477753911,"identity":"a8d5c7fc-fbef-4fef-9337-4b977e09f37f","order_by":5,"name":"Raymond Kiwesa","email":"","orcid":"","institution":"President’s Office Regional Administration and Local Government, Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Raymond","middleName":"","lastName":"Kiwesa","suffix":""},{"id":477753913,"identity":"382541cd-b47f-472f-8441-643217027f77","order_by":6,"name":"Gabrielle Applefo","email":"","orcid":"","institution":"Independent consultant","correspondingAuthor":false,"prefix":"","firstName":"Gabrielle","middleName":"","lastName":"Applefo","suffix":""},{"id":477753914,"identity":"8a0d6a6a-b84e-45a9-b3c1-c79eacfbca6d","order_by":7,"name":"Wendy Erasmus","email":"","orcid":"","institution":"UNICEF, Tanzania","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Erasmus","suffix":""},{"id":477753915,"identity":"33a79ce5-111a-42ac-bf95-eeba0d2ccd68","order_by":8,"name":"Carl Schutte","email":"","orcid":"","institution":"Genesis Analytics","correspondingAuthor":false,"prefix":"","firstName":"Carl","middleName":"","lastName":"Schutte","suffix":""}],"badges":[],"createdAt":"2025-03-26 07:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6309932/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6309932/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-02985-w","type":"published","date":"2025-10-08T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85764780,"identity":"ce307c90-8826-4abb-a2be-4a3ead655d8a","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25364,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of OPD visits in FY 2021/22 and 2022/23 by region\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/e171fa097cf1af1c5ffbc815.png"},{"id":85764781,"identity":"87091b69-4672-410b-b3e6-75841062acd4","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":25327,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of IPD visits in FY 2021/22 and 2022/23 by region\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/7d13734455cd2399d5b7087a.png"},{"id":85764782,"identity":"3a557eab-2f99-4dc8-8025-2903f33d7744","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":14722,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTotal actual Government and donors on budget expenditure on PHC in FY 2021/22 and 2022/23\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/192d9d4452d37b3d954d1395.png"},{"id":85764784,"identity":"2e56de37-9dc6-4caf-9bbd-acceab1a2bd0","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":22593,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTotal actual Government spending on PHC in FY 2022/23\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/7ba982e583bcb1b043c59655.png"},{"id":85764789,"identity":"7fa9dece-1d42-48b1-9920-547b71d85662","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":16567,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNormative cost estimated for FY 2021/22 and 2022/23\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/42559bd681a16329edce4161.png"},{"id":85765689,"identity":"bc54e9b5-f43c-4a2b-a389-514aa12d939d","added_by":"auto","created_at":"2025-07-01 12:26:16","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":17678,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of the funding gap analysis in FY 2021/22 and 2022/23\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/7e297e595df5b9eae6aa0c7b.png"},{"id":85764788,"identity":"1bf8faa7-af26-436e-8b27-d05d10359c3b","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":28517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationship between Government PHC spending and skilled delivery\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/390ebfb85d2a6dff8de0c1ff.png"},{"id":85765690,"identity":"6594695c-46c6-445f-a40b-755a0a973890","added_by":"auto","created_at":"2025-07-01 12:26:16","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":28243,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationship between Government PHC spending and U5 mortality\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/880eab552c8ecc54e380a12d.png"},{"id":85764791,"identity":"017edd1f-5a04-4d54-a622-c08abd08da03","added_by":"auto","created_at":"2025-07-01 12:18:16","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":23319,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelationship between Government PHC spending in regions and under-5 mortality\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/ccc7506700a6f46abce9947c.png"},{"id":93419566,"identity":"f65e1501-e9f8-449a-a85b-3d24ac231d8e","added_by":"auto","created_at":"2025-10-13 16:04:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1228339,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6309932/v1/1c9758c2-0d7b-486e-a05c-a385105bfaac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unlocking value: a comprehensive costing study of Primary Health Care service delivery in Tanzania ","fulltext":[{"header":"Background","content":"\u003cp\u003eTanzania has made significant strides in improving the health of its population over the last two decades. The neo-natal mortality ratio declined from 112 deaths per 1,000 live births (LBs) in 2004-2005 to 43 deaths per 1,000 LBs in 2022; similarly, infant mortality halved, dropping from 68 to 33 deaths per 1,000 LBs during the same period, and skilled attendance during delivery increased from 47% in 2004-2005 to 85% in 2022 (1) (2). These enhancements stemmed from an expansion in the number of health facilities, improved medicines availability, greater domestic funding, and the strengthening of governance by implementing decentralisation by devolution\u0026nbsp;(3). However, further progress is needed to improve health outcomes and achieve the Sustainable Development Goals.\u003c/p\u003e\n\u003cp\u003eTanzania remains heavily reliant on donor funding for health service delivery. Such funding is highly fragmented with only a fraction of the resources directed through the Health Basket Fund, the health sector’s on-budget donor funding pooling mechanism. Foreign-funded projects that are implemented through government authorities are reported by the Accounting Officers through the Direct to Project Funds Modality (D-Funds) and do not appear on the Medium-Term Expenditure Framework. Private expenditure on healthcare is also high, representing 27% of the current health expenditure in 2022 (4). Out-of-pocket expenditures account for the largest share (26%) of private expenditures in the form of user fees collected and retained at the health facility level (5).\u003c/p\u003e\n\u003cp\u003eTanzania has long prioritized PHC as the pathway to achieving universal health coverage\u0026nbsp;(6). Nevertheless, greater, and better investments are needed to expand access to quality PHC services and further improve population health outcomes. As Tanzania graduated to lower-middle-income country status in 2020, the government is expected to incrementally increase domestic financing of health services. To support this aim, there is a need to estimate the current expenditure of PHC service, the resources needed to deliver quality PHC services according to Government-defined standards, and the gap between the two.\u003c/p\u003e\n\u003cp\u003eSeveral studies have been conducted on the Tanzania mainland to estimate the costs of delivering individual health interventions (7) (8). However, no comprehensive costing exercise has been recently conducted to estimate government expenditure on PHC service delivery and the gap vis à vis the resources needed to deliver quality PHC services. To address this information gap, the President’s Office Regional Administration and Local Government (PORALG) and the Ministry of Health (MoH) partnered with UNICEF to undertake a comprehensive PHC costing exercise. The study aimed to generate estimates to inform domestic resource allocation for the equitable delivery of quality PHC services.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy Setting\u003c/h2\u003e\n\u003cp\u003eIn Tanzania, the public health sector is divided between the central and local government, encompassing both the ministerial and the regional administration tier. The MoH leads health policy development and implementation. At the sub-national level, the Tanzania mainland is divided into 25 regions that are an administrative extension of the central government. The local government is divided into 184 Local Government Authorities (LGA) responsible for decentralised public services delivery, including health, and report to the PORALG (9).\u003c/p\u003e\n\u003cp\u003eIn mainland Tanzania, PHC services are delivered through a multi-layered system. This comprises over 6,000 public dispensaries, health centers, and district hospitals, offering a comprehensive approach to health encompassing promotion, prevention, treatment, rehabilitation, and palliative care. A detailed description of the services provided at the different levels is contained in various policy documents (10) (11), but a summary of responsibilities is as follows:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAt the community level, health workers engage in health promotion and prevention activities in neighbourhoods and villages.\u003c/li\u003e\n \u003cli\u003eThe village level provides preventive and curative outpatient services through dispensaries serving between 6,000 and 10,000 people. Clinical assistants and enrolled nurses supervise dispensaries.\u003c/li\u003e\n \u003cli\u003eThe ward level serves as the referral point for the village level, with health centers offering more extensive services, including inpatient care. Health centers are led by clinical officers, supported by enrolled nurses, and serve approximately 50,000 people.\u003c/li\u003e\n \u003cli\u003eDistrict hospitals represent the next level, providing specialised medical care and functioning as teaching hospitals for medical, paramedical, and nursing training. District hospitals employ medical doctors and nursing officers and cater to the district population, which varies significantly by district.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMultiple districts are clustered into zones, each of which has a regional hospital, and at the top of the pyramid are specialised hospitals overseen by the MoH.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eScope of the costing exercise\u003c/h2\u003e\n\u003cp\u003eThe overarching aim of this study was to develop national estimates of the total financial costs for the full package of PHC services. The study had three specific objectives. First, to understand the expenditure incurred by the government to deliver PHC services (i.e. actual costs) in FY 2021/22 and 2022/23; secondly to estimate the total resources needed to deliver quality PHC services as per the Basic Health Service Standards (i.e. normative costs); and finally, to calculate the gap between actual costs and the normative costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe costing assumed a provider’s perspective and estimated the expenditure incurred by the government to provide health services in public health facilities. As a first step, actual total expenditure was estimated for PHC service delivery by the level of the facility. The second step consisted of the estimation of total resources needed, using normative costing, to provide PHC services. The final step involved the calculation of the resource gap between the actual cost of providing PHC services and the estimated total resource need.\u003c/p\u003e\n\u003ch2\u003eScenarios for Costing\u003c/h2\u003e\n\u003cp\u003eThe cost of PHC service delivery was estimated for two different scenarios: the current scenario using actual expenditure in FY 2021/22 and 2022/23, and the normative scenario.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIn the \u003cstrong\u003eActual Expenditure Scenario\u003c/strong\u003e, the actual government expenditure incurred in PHC facilities was used to indicate the total expenditure incurred by the government to provide PHC services.\u003c/li\u003e\n \u003cli\u003eThe \u003cstrong\u003eNormative Scenario\u003c/strong\u003e considered the resource requirement for service delivery using the 2017 Basic Service Standards, fully implemented, at all PHC levels without any adjustment.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe difference between the current and the normative scenarios allowed for the estimate of the total resource gap across the different levels of service delivery and service delivery inputs.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCosting Approach\u003c/h2\u003e\n\u003cp\u003eA top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included. Costs incurred at the regional and national levels (e.g. supportive supervision), and by off-budget development partners to support PHC services were excluded from the analysis.\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eApproach for estimating costs under the actual expenditure scenario\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eAll facility and community-level expenditures incurred by the government in dispensaries, health centers, and district hospitals on human resources, medicines, medical supplies, and facility operations in FY 2021/22 and 2022/23 were collected and included.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cem\u003eApproach for estimating costs under the normative scenario\u003c/em\u003e\u003c/h3\u003e\n\u003cp\u003eThe resources needed for human resources (HR) were estimated using facilities as the unit of analysis. The number of HR in the staff establishment of the Basic Health Services Standards was multiplied by the government remuneration by cadre. The total normative HR cost per facility was a summation of the total computed remuneration of all cadres, and the total normative HR cost for PHC services per level of facility was obtained by multiplying all government facilities of that level by the HR cost of a standard facility. The country’s normative HR cost comprised the summation across all the facility types.\u003c/p\u003e\n\u003cp\u003eThe cost of health commodities was based on the current estimated requirements by facilities, captured in the national quantification, supplemented by the programme quantifications for HIV, malaria, tuberculosis, and leprosy. The national quantification for essential medicines was adjusted to reflect the reported underestimation by 28% in FY 2021/22 and 26% in FY 2022/23.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNormative operational costs were assumed to be equal to the actual expenditure on operations incurred by the facilities.\u003c/p\u003e\n\u003ch2\u003eData sources\u003c/h2\u003e\n\u003cp\u003eThe study relied on secondary data generated largely through government routine systems. The normative costing entailed estimating the cost of HR using the Basic Health Services Standards. HR costs were added to the health commodities resource requirements obtained from the national quantification reports for FY 2021/22 and 2022/23 and operation costs from the Facility Financing and Accounting Reporting System (FFARS). The data sources consisted of FFARS for facility expenditure, PlanRep for HR expenditure incurred directly by the Ministry of Finance (MoF), the Medical Stores Department (MSD) for health commodities procured and supplied through government funding, and the District Health Information Softeward 2 (DHIS2) for service utilisation. Relevant stakeholders were consulted in their professional capacity to assess the accuracy of the national quantification of health commodities and appropriate adjustments made.\u0026nbsp;\u003cstrong\u003eTable 1\u003c/strong\u003e provides an overview of the different types of data, sources, and uses of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Data type, sources, and uses of the data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eData type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUses of the data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpenditure by facility type (HR, health commodities, facility operations)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFFARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eActual expenditure on medicines, supplies, operating costs, and HR directly procured by the facility.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpenditure on medicines and supplies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMSD reports and FFARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEstimate actual expenditure on commodities incurred via MSD and procurement from private vendors by facilities.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePersonnel emoluments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlanRep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBudget values as proxy for expenditure on centrally remunerated staff, which was not included in FFARS for PHC facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormative estimate for personnel emolument\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBasic Health Service Standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGuides the analysis of total HR needs at facilities to underpin the normative costing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNormative estimate of medical supplies, reagents, medical equipment and pharmaceuticals \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNational quantification report, vertical programme quantification for ARVs and malaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsed to estimate the normative value of health commodities and supplies\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCapital expenditure for future facility development and infrastructure expansion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of health facilities registered on FFARS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSupports estimates for capital development costs and other capital expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eData analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe costing was undertaken using Excel-based analysis tools. Estimates were compiled for individual cost inputs (i.e. HR, health commodities, and facility operating costs) by region and by level of facility (i.e. dispensary, health centre, and district hospital) and aggregated to generate national and regional estimates. In addition, high-level unit costs were calculated for outpatient equivalent visits for each region and nationally. In-patient days were adjusted by a factor of four to convert them to outpatient equivalent days.\u003c/p\u003e\n\u003cp\u003eAll estimates were converted to USD using the exchange rate of 1 USD = 2,298 TZS for FY 2021/22 and 1 USD = 2,310 TZS for FY 2022/23 (Bank of Tanzania average mean exchange rate).\u003c/p\u003e\n\u003ch2\u003eQuality assurance and validation\u003c/h2\u003e\n\u003cp\u003eThe data obtained from the described sources were triangulated with others (e.g. the National Health Accounts) and other costing studies employing different methodologies to assess their quality and identify anomalies. The cost calculations and analysis spreadsheets were also checked for accuracy, completeness, and reasonableness. Representatives from the PORALG Health, Social Welfare, and Nutrition Services Directorate, the MoH, the MoF, UNICEF, and other development partners validated data and outputs during a technical review session.\u003c/p\u003e\n\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eEthical approval was initially granted by the National Institute for Medical Research in Tanzania on October 7\u003csup\u003eth\u003c/sup\u003e, 2021, with reference number NIMRHQR8a/ Vol/IX / 3797. Subsequently, a protocol amendment was approved on January 25\u003csup\u003eth\u003c/sup\u003e, 2024.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eHealth facility service utilization\u003c/h2\u003e\n\u003cp\u003eIn FY 2021/22 and FY 2022/23 there were 5,719 and 6,042 government-owned PHC facilities across Tanzania mainland. Over the two years, 61,302,737 and 39,008,713 outpatient visits were provided, as well as 619,614 and 659,005 inpatient visits (\u003cstrong\u003eFigure 1\u003c/strong\u003e, \u003cstrong\u003eFigure 2\u003c/strong\u003e). The significant reduction in the number of outpatient visits could be explained in relation to data reporting challenges.\u003c/p\u003e\n\u003cp\u003eActual Government spending on PHC\u003c/p\u003e\n\u003cp\u003eThe study found that total expenditure on PHC from the central government, the National Health Insurance Fund, the Community Health Fund, the Health Basket Fund, and other on-budget donors grew from TZS 801 billion (USD 349 million) to TZS 1,158 billion (USD 501 million) between FY 2021/22 and FY 2022/23 (\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;3\u003c/strong\u003e). The significant growth is attributed to the rise in the expenditure on HR due to the increase in the health personnel employed, mostly at the level of district hospitals, in FY 2022/23, and the growth in facility operating costs resulting from the operationalisation and upgrade of 310 health facilities. Expenditure on health commodities, comprising pharmaceuticals, reagents, and equipment, marginally decreased between the two years, especially in dispensaries. No reasons were attributed to this beyond those related to the operationalisation and upgrade of 310 health facilities.\u003c/p\u003e\n\u003cp\u003eWhile total per capita expenditure on PHC increased from TZS 12,891 (USD 5.61) to TZS 18,215 (USD 7.89) between the two years, implying a more than proportional increase compared to the population growth, it remained significantly lower than the WHO recurrent PHC benchmark of TZS 136,900 (USD 59) (12). The analysis of government expenditure in PHC at the regional level also revealed significant disparities. The lowest government expenditure on PHC was reported in Simiyu and was less than a third of the expenditure in Njombe, the region with the highest level of government spending (\u003cstrong\u003eFigure 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eExpenditure per standard unit of output, measured using outpatient visits, nearly doubled in all regions between FY 2021/22 and FY 2022/23. This finding suggests that despite increased expenditure on PHC, there was no significant improvement in health service access.\u003c/p\u003e\n\u003ch2\u003eNormative costing for PHC\u003c/h2\u003e\n\u003cp\u003eThe normative costing revealed that TZS 4,519 billion (USD 1,966 million) and TZS 6,384 billion (USD 2,997 million) are needed to deliver quality PHC services according to the national Basic Health Services Standards. The sharp increase between the two years was primarily driven by the health commodity needs which grew due in response to the increased number of health facilities. The greater growth in commodity needs was reported at the dispensary level, followed by district hospitals. The analysis reveals that normative HR costs rose with the increase in registered facilities. The increase in HR needs between FY 2021/22 and FY 2022/23 was 10%, 10%, and 7% for dispensaries, health centres, and district hospitals, respectively (\u003cstrong\u003eFigure\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eThe estimate of normative per capita cost shows that if the Government of Tanzania aligned its investment in PHC to the FY 2023/24 normative estimate of TZS 50,797 per capita, it would move towards achieving the WHO target of per capita PHC recurrent expenditure of TZS 136,900 (USD 59) (12).\u003c/p\u003e\n\u003ch2\u003eFunding gap analysis\u003c/h2\u003e\n\u003cp\u003eThe gap analysis revealed that in FY 2021/22 and FY 2022/23, there was an 84% and 83% government funding gap for the delivery of quality PHC services, estimated as the difference between the normative costs and the sum of central government, Community Health Fund, and National Health Insurance Fund contributions. Due to the contributions of development partners and individuals paying for services out-of-pocket, the actual gap is likely lower than this estimate but remains significant (\u003cstrong\u003eFigure \u003cem\u003e6\u003c/em\u003e\u003c/strong\u003e)\u003cstrong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile district hospitals had the highest proportional funding gap in FY 2021/22, dispensaries accounted for 49% of the total funding gap in FY 2022/23. This change in proportions can be attributed to the increased number of facilities and the disproportionate increase in the commodity and staffing costs in FY 2022/23 in dispensaries (\u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Funding gap analysis by level of service delivery\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFY 2021/22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFY 2022/23\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActual\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActual\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFunding gap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eDispensary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e287\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e847\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e560\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1,141\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e747\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHealth Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e260\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e535\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e271\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e478\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e713\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,730\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,063\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2,563\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,500\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003ch2\u003eRelationship between spending, outputs, and outcomes\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eFigures 7-9\u003c/strong\u003e show the relationship between current per capita expenditure for each region and skilled delivery, antenatal care (ANC) utilisation and mortality for children under-5 years for the same regions. A trend line has been included based on the observations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the first two indicators, there is a clustering of regions in terms of per capita expenditure but significant variability in health indicator values. There seems little correlation between per capita expenditure and under-5 mortality. Notwithstanding that funding plays a critical role in increasing the availability of and access to health services, it should be noted that service utilisation for skilled delivery and ANC depends on many factors, including health-seeking behaviour. Under-five mortality depends on previous spending and other factors, and it may not be possible to draw conclusions from this analysis. Overall, the results show a positive relationship between government PHC per capita spending and service utilisation (skilled delivery and ANC 4+) and a weak, negative relationship with under-five mortality with high variability around the trend line. Nevertheless, these results underscore the important role of government financing in improving the welfare of its population. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study found that total per capita expenditure on PHC increased in the two years, implying a more than proportional increase compared to the population growth. However, expenditure remained significantly lower than the WHO per capita spending benchmark. The study also found high variation in expenditure and productivity across regions in Tanzania with implications for equitable access to PHC services. In-country variation may be partly attributed to the extent of donor off-budget support channelled to specific regions. Some inequity may be mitigated through such support, but further analysis is required to accurately assess the situation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePer capita health expenditure is an indicator that can be used to assess equity in funding health services across geographies and populations and is commonly reported in national costing and expenditure tracking. It is particularly helpful when it is combined with the burden of diseases in different regions. Relative benchmarking with other PHC systems within the region may also serve to highlight areas for improvement, recognizing that substantial variation exists in PHC models among countries. As noted very little work has been done to develop detailed definitions of what PHC encompasses making comparison difficult (12).\u0026nbsp;The\u0026nbsp;Primary Health Care Performance Initiative was designed to support the measurement of PHC-related variables, including PHC expenditure per capita as one recommended indicator with the understanding that PHC is the ‘cornerstone’ of sustainable development, and improvement is premised on better data and measurement\u0026nbsp;(13).\u003c/p\u003e\n\u003cp\u003eCosting studies are an important tool to\u0026nbsp;reduce gaps in coverage of populations, services, and expenditures. They are particularly important sources of information in contexts of transition from donor to domestic financing. In Tanzania, there is no domestic resource mobilization strategy for the health sector and the government’s allocation lags that of most neighbouring countries in the region. While domestic healthcare financing has improved, resources have not kept pace with inflation and population demand. Given changing donor resource availability, coupled with Tanzania’s transition to lower middle-income status, more work is needed to identify effective financing mechanisms for the health sector. Increasingly costing studies of PHC services are available and can be used as ‘guide posts’ for investment and projected resource needs (12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe evidence generated by this study can be used to develop a robust advocacy strategy for more government and domestic resources for PHC services. Additionally, there is a need to reevaluate allocation to regions where the current PHC spending was indicative of unequal per capita expenditure, noting that it may not be possible to reduce historical allocations. Lastly, institutionalisation of the costing approach and related reporting is recommended so that MoH and PORALG can use it routinely to inform planning and ongoing management of health facilities.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThere were some limitations to the study. The data on direct payment for HR by the Central Government contained only personnel emoluments and did not capture allowances paid by the MoF. Therefore, the allowances were estimated based on the results of phase one of the costing study which include a sample of 70 facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe estimated need for commodities was taken from the quantification reports and adjusted for underestimation based on expert opinion and comparisons of estimates with actual expenditure. Additionally, there was a big difference between the estimated commodities needs for the two years which points to a forecasting and estimation process which is maturing and may contain inaccuracies. In theory, quantification starts as a process which considers prior year consumption and as such, may imbed inefficiencies and not be a true reflection of need. However, quantities for vertical programmes are based on the burden of disease and population coverage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis also relied on service data reported from the DHIS2, which may be subject to completeness errors in reporting by health facilities. However, these data were used only for the estimation of cost per outpatient equivalent visit and do not impact on other reported results.\u003c/p\u003e\n\u003cp\u003eIdeally, the analysis would consider a scenario that considers affordability and other constraints, referred to as a Feasible Scenario. This scenario would generate a total resource need below that generated by the normative costing and would adjust, for example, staff establishments for output and setting, which the Basic Health Services Standards do not go beyond the classification of the health facility. \u0026nbsp;It was not possible to generate a Feasible Scenario due to the lack of reliable data to underpin assumptions. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study shows that the central government plays a critical role in financing PHC in the country. The government’s PHC spending increased significantly over the two-year period, raising the per capita PHC expenditure and the expenditure per outpatient visit. The increase was largely attributable to the salaries of public servants and the increased numbers of staff employed by the government. Reaching WHO per capita spending benchmarks for lower-middle-income countries will nevertheless require significantly more sustainable domestic resources and investment. As the Government of Tanzania increasingly finances health services from domestic sources, a key consideration for long-term planning in the context of declining partner funding is the total amount of funding required to provide quality services equitably to the population. At the same time, a more detailed understanding of current PHC expenditure informs the calculation and estimation of the funding gap. \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Antenatal care\u003c/p\u003e\n\u003cp\u003eD-Funds\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Direct to Project Funds Modality\u003c/p\u003e\n\u003cp\u003eDHIS2\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;District Health Information System\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFFARS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Facility Financing and Accounting Reporting System\u003c/p\u003e\n\u003cp\u003eFY\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Fiscal year\u003c/p\u003e\n\u003cp\u003eHR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Human resources\u003c/p\u003e\n\u003cp\u003eLB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Live births\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMOF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ministry of Finance\u003c/p\u003e\n\u003cp\u003eMOH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ministry of Health\u003c/p\u003e\n\u003cp\u003eMSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Medical Stores Department\u003c/p\u003e\n\u003cp\u003ePHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;primary health care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePORALG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;President’s Office Regional Administration and Local Government\u003c/p\u003e\n\u003cp\u003eTZS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Tanzania Shillings\u003c/p\u003e\n\u003cp\u003eUSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;United States Dollar\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e All data came from the Goverment financial systems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish declaration:\u0026nbsp;\u003c/strong\u003enot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics:\u0026nbsp;\u003c/strong\u003eEthical approval was granted by the National Institute for Medical Research in Tanzania on October 7th, 2021, with reference number NIMRHQR8a/ Vol/IX / 3797. Subsequently, a protocol amendment was approved on January 25th, 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The funding was from the Swiss Agency for Development and Cooperation and Global Affairs Canada.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDesign of the study was done by FM, WCM, NK, JTK, DM, RK, CS.\u003c/li\u003e\n \u003cli\u003eAcquisition and analysis for the study was done by FM and CS.\u003c/li\u003e\n \u003cli\u003eInterpretation of findings was done by FM, WCM, NK, JTK, DM, RK and CS.\u003c/li\u003e\n \u003cli\u003eThe study was written by FM and CS with inputs from WCM, NK, JTK, DM, RK, GA and WE.\u003c/li\u003e\n \u003cli\u003eThe manuscript was written by FM and GA.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAll authors reviewed the manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAcknowledgements: We wish to acknowledge the generous support provided by the Swiss Agency for Development and Cooperation as well as Global Affairs Canada. We further wish to acknowledge the Health Basket Fund partners and the Government of Tanzania for their feedback and contributions to this study and unwavering commitment to the delivery of primary healthcare for the people of Tanzania.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMinistry of Health (MoH) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2022. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report. Dodoma, Tanzania, and Rockville, Maryland, USA: MoH, NBS, OCGS, and ICF.\u003c/li\u003e\n \u003cli\u003eNational Bureau of Statistics (NBS) [Tanzania] and ORC Macro. 2005. Tanzania Demographic and Health Survey 2004-05. Dar es Salaam, Tanzania: National Bureau of Statistics and ORC Macro.\u003c/li\u003e\n \u003cli\u003eUnited Republic of Tanzania, Ministry of Health, Community Development, Gender,, Elderly and Children. Health Sector Strategic Plan July 2021 \u0026ndash; June 2026 (HSSP V) [Internet]. Available from: https://mitu.or.tz/wp-content/uploads/2021/07/Tanzania-Health-Sector-Strategic-Plan-V-17-06-2021-Final-signed.pdf\u003c/li\u003e\n \u003cli\u003eUNICEF, 2022. Tracking off-budget financial resources in the health sector, FY 2021-22.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization, Global Health Expenditures Database. https://apps.who.int/nha/database/Home/Index/en/ [accessed 29/11/2024].\u003c/li\u003e\n \u003cli\u003eKapologwe NA, Meara JG, Kengia JT, Sonda Y, Gwajima D, Alidina S, et al. Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: a strategy towards achieving universal health coverage in Tanzania. BMC Health Serv Res. 2020 Mar 17;20(1):218.\u003c/li\u003e\n \u003cli\u003eVaughan K, Clarke-Deelder E, Tani K, Lyimo D, Mphuru A, Manzi F, Sch\u0026uuml;tte C, Ozaltin A. Immunization costs, from evidence to policy: Findings from a nationally representative costing study and policy translation effort in Tanzania. Vaccine. 2020 Nov 10;38(48):7659-7667. doi: 10.1016/j.vaccine.2020.10.004. Epub 2020 Oct 17. PMID: 33077300; PMCID: PMC7604567.\u003c/li\u003e\n \u003cli\u003evon Both C, Jahn A, Fleba S. Costing maternal health services in South Tanzania: a case study from Mtwara Urban District. Eur J Health Econ. 2008 May;9(2):103-15. doi: 10.1007/s10198-007-0048-3. Epub 2007 Apr 24. PMID: 17453262.\u003c/li\u003e\n \u003cli\u003eBoex, J, Fuller, L. and Malik, A. Decentralized Local Health Services in Tanzania: Are Health Resources Reaching Primary Health Facilities, or Are They Getting Stuck at the District Level? [Internet]. Urban Institute; 2015. Available from: https://www.urban.org/sites/default/files/publication/51206/2000215-Decentralized-Local-Health-Services-in-Tanzania.pdf\u003c/li\u003e\n \u003cli\u003eThe United Republic of Tanzania Ministry of Health (MoH) and President\u0026rsquo;s Office, Regional Administration and Local Government (PORALG), 2022.The Primary Health Services Implementation Development Strategy (PHSIDS) 2022-2032. (MoH \u0026amp; PORALG: Tanzania).\u003c/li\u003e\n \u003cli\u003eThe United Republic of Tanzania Ministry of Health, Community Development , Gender, Elderly and Children (2017). Basic Standards for Health Facilities: Dispensaries, Health Centres, Stand Alone Dental Cllinics and Rehabilitation Medicine Facilities (MoHCDGEC: Tanzania).\u003c/li\u003e\n \u003cli\u003eStenberg K, Hanssen O, Bertram M, Brindley C, Meshreky A, Barkley S, Tan-Torres Edejer T. Guide posts for investment in primary health care and projected resource needs in 67 low-income and middle-income countries: a modelling study. Lancet Glob Health. 2019 Nov;7(11):e1500-e1510. doi: 10.1016/S2214-109X(19)30416-4. Epub 2019 Sep 26. PMID: 31564629; PMCID: PMC7024989.\u003c/li\u003e\n \u003cli\u003eVeillard J, et al. Better Measurement for Performance Improvement in Low- and Middle-Income Countries: The Primary Health Care Performance Initiative (PHCPI) Experience of Conceptual Framework Development and Indicator Selection. Millbank Q. 2017;95(4).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6309932/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6309932/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Tanzania has long prioritized primary health care (PHC) as the pathway to achieving universal health coverage. However, greater, and more effective investments are needed to expand access to quality PHC services and further improve population health outcomes. Furthermore, as Tanzania graduated to lower-middle-income country status, the Government is expected to move towards full domestic financing of health services. To support this aim, there is a need to estimate the current expenditure of PHC services, the resources needed to deliver quality PHC services according to nationally defined standards, and the gap between the two.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA top-down approach was used to understand the costs incurred by the government to provide PHC services in public health facilities. All facility and community-level expenditures incurred by the government and development partners on human resources, medicines, medical supplies, and facility operations were collected and included. The total funding gap was calculated as the difference between actual expenditure and estimated normative cost. The gap analysis was undertaken by input categories and level of facility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Government expenditure on PHC substantially increased between fiscal year (FY) 2021/22 and 2022/23. Nevertheless, the spending level is significantly lower than global benchmarks, and the resources required to deliver quality PHC services according to the basic service standards. Moreover, the analysis revealed there are important differences in the levels of spending per capita across regions and health service delivery productivity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe Government of Tanzania’s PHC spending increased significantly over the two years, raising the per capita PHC expenditure and the expenditure per outpatient visit. As the Government of Tanzania increasingly finances health services from domestic sources, a key consideration for long-term planning in the context of declining partner funding is the total amount of funding required to provide quality PHC services equitably to the population. At the same time, a more detailed understanding of current PHC expenditure informs the calculation and estimation of the funding gap.\u003c/p\u003e","manuscriptTitle":"Unlocking value: a comprehensive costing study of Primary Health Care service delivery in Tanzania ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 12:18:11","doi":"10.21203/rs.3.rs-6309932/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-31T10:20:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T11:37:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-18T22:25:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T09:28:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242055383956353553197083988687529625441","date":"2025-06-27T16:39:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27334587282665686556751746443829725325","date":"2025-06-27T11:43:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"283048467155246816964037083940319565713","date":"2025-06-26T16:15:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-26T13:47:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T15:43:50+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-04T09:42:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-04T06:27:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-06-04T06:23:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a7f72b0-2b10-464f-afb9-3a7cf56be9cd","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T15:59:27+00:00","versionOfRecord":{"articleIdentity":"rs-6309932","link":"https://doi.org/10.1186/s12875-025-02985-w","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-10-08 15:56:51","publishedOnDateReadable":"October 8th, 2025"},"versionCreatedAt":"2025-07-01 12:18:11","video":"","vorDoi":"10.1186/s12875-025-02985-w","vorDoiUrl":"https://doi.org/10.1186/s12875-025-02985-w","workflowStages":[]},"version":"v1","identity":"rs-6309932","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6309932","identity":"rs-6309932","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}