Respondent characteristics by role.

Health systems in low- and middle-income countries often face severe resource constraints and are implementing reforms to improve accountability and efficiency. Healthcare managers and governance structures are key for the successful implementation of these reforms. This study aimed to examine the implementation of the Direct Health Facility Financing (DHFF), focusing on the perspectives of health facility in-charges and members of Council Health Management Teams (CHMTs). This study employed a cross-sectional web-based questionnaire administered to all heads of public health facilities and members of CHMTs in the Kilimanjaro and Morogoro. First, we analyzed the demographics of healthcare managers, characteristics of health facilities, and the reported implementation of DHFF governance. We then performed multivariate ordered logistic regressions analyses to examine the associations between healthcare managers’ perceptions of DHFF implementation, reported changes, and resource allocation changes while controlling for health managers and facility characteristics. 348 health managers participated in the study. 23% of health facility in-charges had received DHFF-related training in the previous 12 months. 76% reported that supportive supervision explicitly includes DHFF considerations. 92% of CHMTs reported a decrease in administrative workload following DHFF implementation, compared to 80% of facility managers. Positive perceptions of autonomy in planning, budgeting and fund management were widespread (88% facility in-charge and 95% CHMTs). Health managers with higher levels of education reported positive perceptions of strong DHFF governance. Urban facilities were more likely to report higher overall DHFF governance. As the number of staff trained in DHFF increased, the positive perceptions of challenges also increased. Facility managers with a university degree perceived a successful impact of DHFF in increasing their financial resources. This study suggests that the implementation of the DHFF was positively received by health facility managers. The DHFF appears to have led to improvements in resource mobilization and financial incentives potentially contributing to overall efficiencies.