Navigating the Challenges of Primary Health Care in Selected Local Government Authorities in Tanzania: Bringing Lipsky’s Theory in Its Requisite Panorama

Abstract

Introduction: The robust delivery of primary health care (PHC) service is a complex interplay of key stakeholders, including policymakers, citizens, the government, parliamentarians, academics, and street-level bureaucrats - health staff in this context. While each of these players has a stake in ensuring robust PHC delivery, this paper specifically examines the role of street-level bureaucrats (SLBs) in dealing with service delivery challenges in Local Government Authorities (LGAs) in Tanzania. Although the engagement with these actors gained momentum in the decentralization reforms of the 1990s, their contribution has been slow. The question remains: How can SLBs cope with LGAs’ predicaments to enhance service delivery?  Lipsky’s (1980) theory focuses on this contention by proposing that under challenging encounters, SLBs can develop specific patterns of practices to deal with the status quo.

Methods: Data were collected through interviews with policymakers at Mvomero District and Moshi Municipal Councils. To assess the effectiveness of primary health care services attributes such as authority, accountability, and access were closely examined. A thematic review of the literature was conducted to corroborate the findings from the interviews.

Results: The findings indicate that SLBs can cope with complex and challenging situations related to PHC delivery by rationing resources, simplifying their work environment, or exiting from turbulent environments. Although the engagement of SLBs gained momentum during the decentralization reforms of the 1990s, their contribution has been slow. The primary factor hindering their effectiveness is the inability to establish a mutually beneficial relationship between the Central Government and LGAs.

Conclusion: The government's attempts to control SLBs' behaviors, including limiting their intrinsic and extrinsic motivation, undermine their client responsiveness. Empowering SLBs and fostering a more collaborative relationship between the central government and LGAs is essential to enhance PHC delivery.