Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions

Economic consequences of caesarean section delivery: evidence from a household survey in Tanzania

BACKGROUND

Caesarean section (C-section) delivery is an important indicator of access to life-saving essential obstetric care. Yet, there is limited understanding of the costs of utilising C-section delivery care in sub-Saharan Africa. Thus, we estimated the direct and indirect patient cost of accessing C-section in Tanzania.

METHODS

Cross-sectional survey data of 2012 was used, which covered 3000 households from 11 districts in three regions. We interviewed women who had given births in the last 12 months before the survey to capture their experience of care. We used a regression model to estimate the effect of C-section on costs, while the degree of inequality on C-section coverage was assessed with a concentration index.

RESULTS

C-section increased the likelihood of paying for health care by 16% compared to normal delivery. The additional cost of C-section compared to normal delivery was 20 USD, but reduced to about 11 USD when restricted to public facilities. Women with C-section delivery spent an extra 2 days at the health facility compared to normal delivery, but this was reduced slightly to 1.9 days in public facilities. The distribution of C-section coverage was significantly in favour of wealthier than poorest women (CI = 0.2052, p < 0.01), and this pro-rich pattern was consistent in rural districts but with unclear pattern in urban districts.

CONCLUSIONS

C-section is a life-saving intervention but is associated with significant economic burden especially among the poor families. More health resources are needed for provision of free maternal care, reduce inequality in access and improve birth outcomes in Tanzania.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.

Pathways and associated costs of care in patients with confirmed and presumptive tuberculosis in Tanzania: A cross-sectional study

OBJECTIVE

To assess pathways and associated costs of seeking care from the onset of symptoms to diagnosis in patients with confirmed and presumptive tuberculosis (TB).

DESIGN

Cross-sectional study.

SETTING

District hospital in Dar es Salaam, Tanzania.

PARTICIPANTS

Bacteriologically confirmed TB and presumptive TB patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We calculated distance in metres and visualised pathways to healthcare up to five visits for the current episode of sickness. Costs were described by medians and IQRs, with comparisons by gender and poverty status.

RESULTS

Of 100 confirmed and 100 presumptive TB patients, 44% of confirmed patients sought care first at pharmacies after the onset of symptoms, and 42% of presumptive patients did so at hospitals. The median visits made by confirmed patients was 2 (range 1-5) and 2 (range 1-3) by presumptive patients. Patients spent a median of 31% of their monthly household income on health expenditures for all visits. The median total direct costs were higher in confirmed compared with presumptive patients (USD 27.4 [IQR 18.7-48.4] vs USD 19.8 [IQR 13.8-34.0], p=0.02), as were the indirect costs (USD 66.9 [IQR 35.5-150.0] vs USD 46.8 [IQR 20.1-115.3], p<0.001). The indirect costs were higher in men compared with women (USD 64.6 [IQR 31.8-159.1] vs USD 55.6 [IQR 25.1-141.1], p<0.001). The median total distance from patients' household to healthcare facilities for patients with confirmed and presumptive TB was 2338 m (IQR 1373-4122) and 2009 m (IQR 986-2976) respectively.

CONCLUSIONS

Patients with confirmed TB have complex pathways and higher costs of care compared with patients with presumptive TB, but the costs of the latter are also substantial. Improving access to healthcare and ensuring integration of different healthcare providers including private, public health practitioners and patients themselves could help in reducing the complex pathways during healthcare seeking and optimal healthcare utilisation.

Implementing demand side targeting mechanisms for maternal and child health-experiences from national health insurance fund program in Rungwe District, Tanzania

BACKGROUND

Low and middle income countries have adopted targeting mechanisms as a means of increasing program efficiency in reaching marginalized people in the community given the available resources. Design of targeting mechanisms has been changing over time and it is important to understand implementers' experience with such targeting mechanisms since such mechanisms impact equity in access and use of maternal health care services.

METHODS

The case study approach was considered as appropriate method for exploring implementers' and decision-makers' experiences with the two targeting mechanisms. In-depth interviews in order to explore implementer experience with the two targeting mechanisms. A total of 10 in-depth interviews (IDI) and 4 group discussions (GDs) were conducted with implementers at national level, regional, district and health care facility level. A thematic analysis approach was adopted during data analysis.

RESULTS

The whole process of screening and identifying poor pregnant women resulted in delay in implementation of the intervention. Individual targeting was perceived to have some form of stigmatization; hence beneficiaries did not like to be termed as poor. Geographical targeting had a few cons as health care providers experienced an increase in workload while staff remained the same and poor quality of information in the claim forms. However geographical targeting increase in the number of women going to higher level of care (district/regional referral hospital), increase in facility revenue and insurance coverage.

CONCLUSION

Interventions which are using targeting mechanisms to reach poor people are useful in increasing access and use of health care services for marginalized communities so long as they are well designed and beneficiaries as well as all implementers and decision makers are involved from the very beginning. Implementation of demand side financing strategies using targeting mechanisms should go together with supply side interventions in order to achieve project objectives.