How can we elicit health workers' preferences for measures to reduce informal payments? A mixed methods approach to developing a discrete choice experiment in Tanzania.

OBJECTIVE: While discrete choice experiments (DCEs) have been used in other fields as a means of eliciting respondent preferences, these remain relatively new in studying corrupt practices in the health sector. This study documents and discusses the process of developing a DCE to inform policy measures aimed at addressing informal payments for healthcare in Tanzania. DESIGN: A mixed methods design was used to systematically develop attributes for the DCE. It involved five stages: a scoping literature review, qualitative interviews, a workshop with health providers and managers, expert review and a pilot study. SETTING: Dar es Salaam and Pwani regions in Tanzania. PARTICIPANTS: Health workers and health managers. RESULTS: A large number of factors were identified as driving informal payments in Tanzania and thus represent potential areas for policy intervention. Through iterative process involving different methods (qualitative and quantitative) and seeking consensus views by diverse actors, we derived six attributes for a DCE: mode of payment, supervision at the facility level, opportunity for private practice, awareness and monitoring, disciplinary measures against informal payments and incentive payment for staff if a facility has less informal payments. 12 choice sets were generated and piloted with 15 health workers from 9 health facilities. The pilot study revealed that respondents could easily understand the attributes and levels, answered all the choice sets and appeared to be trading between the attributes. The results from the pilot study had expected signs for all attributes. CONCLUSIONS: We elicited attributes and levels for a DCE to identify the acceptability and preferences of potential policy interventions to address informal payments in Tanzania through a mixed-methods approach. We argue that more attention is needed to the process of defining attributes for the DCE, which needs to be rigorous and transparent in order to derive reliable and policy-relevant findings.

Supply-side factors influencing informal payment for healthcare services in Tanzania.

Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.

Effects of Payment for Performance on accountability mechanisms: Evidence from Pwani, Tanzania.

Payment for Performance (P4P) aims to improve provider motivation to perform better, but little is known about the effects of P4P on accountability mechanisms. We examined the effect of P4P in Tanzania on internal and external accountability mechanisms. We carried out 93 individual in-depth interviews, 9 group interviews and 19 Focus Group Discussions in five intervention districts in three rounds of data collection between 2011 and 2013. We carried out surveys in 150 health facilities across Pwani region and four control districts, and interviewed 200 health workers, before the scheme was introduced and 13 months later. We examined the effects of P4P on internal accountability mechanisms including management changes, supervision, and priority setting, and external accountability mechanisms including provider responsiveness to patients, and engagement with Health Facility Governing Committees. P4P had some positive effects on internal accountability, with increased timeliness of supervision and the provision of feedback during supervision, but a lack of effect on supervision intensity. P4P reduced the interruption of service delivery due to broken equipment as well as drug stock-outs due to increased financial autonomy and responsiveness from managers. Management practices became less hierarchical, with less emphasis on bureaucratic procedures. Effects on external accountability were mixed, health workers treated pregnant women more kindly, but outreach activities did not increase. Facilities were more likely to have committees but their role was largely limited. P4P resulted in improvements in internal accountability measures through improved relations and communication between stakeholders that were incentivised at different levels of the system and enhanced provider autonomy over funds. P4P had more limited effects on external accountability, though attitudes towards patients appeared to improve, community engagement through health facility governing committees remained limited. Implementers should examine the lines of accountability when setting incentives and deciding who to incentivise in P4P schemes.

Strengthening national capacities for researching on Social Determinants of Health (SDH) towards informing and addressing health inequities in Tanzania.

BACKGROUND: Tanzania's socio-economic development is challenged by sharp inequities between and within urban and rural areas, and among different socio-economic groups. This paper discusses the importance of strengthening SDH research, knowledge, relevant capacities and responsive systems towards addressing health inequities in Tanzania. METHODS: Based on a conceptual framework for building SDH research capacity, a mapping of existing research systems was undertaken between February and June 2012. It involved a review of national policies, strategies and published SDH-related research outputs from 2005 onwards, and 34 in-depth interviews with a range of stakeholders in Tanzania. RESULTS: The conceptualization of SDH varies considerably among stakeholders and their professional background, but with some consensus that it is linked to "inequities" being a consequence of poverty, poor planning, limited attention to basic humanity and citizenship rights, weak governance structures and inefficient use of available resources. Commonly perceived SDH factors include age, income, education, beliefs, cultural norms, gender, occupation, nutritional status, access to health care, access to safe water and sanitation and child bearing practices. SDH research is in its infancy but gaining momentum. In the absence of a specific "SDH portfolio", SDH research is scattered and hidden within disease specific, poverty-related research and research on universal health coverage. Research is mainly externally funded, which has implications on the focus of context specific SDH research, national priorities and transfer to policy. This create mismatch with population and research capacity needs. CONCLUSION: Most research analysis in the country fails to consider the context specific structural determinants of health and inequities towards a broader understanding of existing vulnerabilities. The challenge is on promoting a culture of critical inter-disciplinary research and analysis that is central to SDH research. Establishing a system to promote collaboration across sectors and strengthen collective capacities for individuals and institutions researching in SDH will augment existing SDH research initiatives and better inform appropriate intersectoral policies towards addressing prevailing health inequities across the country.

Prevalence and social drivers of HIV among married and cohabitating heterosexual adults in south-eastern Tanzania: analysis of adult health community cohort data.

BACKGROUND: In sub-Saharan Africa, the prevalence of HIV among married and cohabiting couples is substantial. Information about the underlying social drivers of HIV transmission in couples is critical for the development of structural approaches to HIV prevention, but not readily available. We explored the association between social drivers, practices, and HIV status among stable couples in Ifakara, Tanzania. DESIGN: Using a cross-sectional design, we analyzed data from a sample of 3,988 married or cohabiting individuals, aged 15 years and older from the MZIMA adult health community cohort study of 2013. Sociodemographic factors (sex, income, age, and education), gender norms (perceived acceptability for a wife to ask her partner to use a condom when she knows he is HIV positive), marriage characteristics (being in a monogamous or a polygamous marriage, being remarried), sexual behavior practices (lifetime number of sexual partners and concurrent sexual partners), health system factors (ever used voluntary HIV counseling and testing), and lifestyle patterns (alcohol use) were used to explore the odds of being HIV positive, with 95% confidence intervals. RESULTS: Prevalence of HIV/AIDS was 6.7% (5.9% males and 7.1% females). Gender norms, that is, perception that a woman is not justified to ask her husband to use a condom even when she knows he has a disease (adjusted odds ratio AOR=1.51, 95% CI 1.06-2.17), marital characteristics, that is, being remarried (AOR=1.49, 95% CI 1.08-2.04), and sexual behavior characteristics, that is, lifetime number of sexual partners (2-4: AOR=1.47, 95% CI 1.02-2.11; 5+: AOR=1.61, 95% CI 1.05-2.47) were the main independent predictors of HIV prevalence. CONCLUSIONS: Among married or cohabiting individuals, the key social drivers/practices that appeared to make people more vulnerable for HIV are gender norms, marriage characteristics (being remarried), and sexual behavior practices (lifetime number of sexual partners). Married and cohabiting couples are an important target group for HIV prevention efforts in Tanzania. In addition to individual interventions, structural interventions are needed to address the gender norms, remarriage, and sexual practices that shape differential vulnerability to HIV in stable couples.

Pay for performance: an analysis of the context of implementation in a pilot project in Tanzania.

BACKGROUND: Pay for performance schemes are increasingly being implemented in low income countries to improve health service coverage and quality. This paper describes the context within which a pay for performance programme was introduced in Tanzania and discusses the potential for pay for performance to address health system constraints to meeting targets. METHOD: 40 in-depth interviews and four focus group discussions were undertaken with health workers, and regional, district and facility managers. Data was collected on work environment characteristics and staff attitudes towards work in the first phase of the implementation of the pilot. A survey of 75 facilities and 101 health workers were carried out to examine facility resourcing, and health worker employment conditions and job satisfaction. RESULTS: Five contextual factors which affect the implementation of P4P were identified by health workers: salary and employment benefits; resource availability, including staff, medicines and functioning equipment; supervision; facility access to utilities; and community preferences. The results suggest that it is important to consider contextual issues when implementing pay for performance schemes in low income settings. It highlights the importance of basic infrastructures being in place, a minimum number of staff with appropriate education and skills as well as sufficient resources before implementing pay for performance. CONCLUSION: Health professionals working within a pay for performance scheme in Tanzania were concerned about challenges related to shortages of resources, limited supplies and unfavourable community preferences. The P4P scheme may provide the incentive and means to address certain constraints, in so far as they are within the control of providers and managers, however, other constraints will be harder to address.

Protocol for the evaluation of a pay for performance programme in Pwani region in Tanzania: a controlled before and after study.

BACKGROUND: The use of supply-side incentives to increase health service utilisation and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is a paucity of evidence on the impact of such schemes, their cost-effectiveness, and the process of implementation and potential unintended consequences in these settings. A pay for performance (P4P) programme was introduced in Pwani region of Tanzania in 2011. METHODS/DESIGN: An evaluation of the programme will be carried out to inform a potential national rollout. A controlled before and after study will examine the effect of the P4P programme on quality, coverage, and cost of targeted maternal and newborn healthcare services and selected non-targeted services at facilities in Tanzania. Data will be collected from a survey of 75 facilities, 750 patients exiting consultations, over 75 health workers, and 1,500 households of women who delivered in the previous year, in all seven intervention districts. Data will be collected from the same number of respondents in four control districts. A process evaluation will examine: whether the P4P programme was implemented as planned; stakeholder response to the programme and its acceptability; and implementation bottlenecks and facilitating factors. Three rounds of process data collection will be conducted including a review of available P4P documents, individual interviews and focus group discussions with key informants working at facility and district level in five of the intervention districts, and at the regional and national levels. An economic evaluation will measure the cost-effectiveness of P4P relative to current practice from a societal perspective. DISCUSSION: This evaluation will contribute robust evidence on the impact and cost-effectiveness of P4P in a low income setting, as well as generate a better understanding of the feasibility of integrating complex intervention packages like P4P within health systems in resource poor settings.

Poor people's experiences of health services in Tanzania: a literature review.

This literature review examines key findings on poor people's experiences of health services and the barriers to access among the very poor. It was first published in 2004 by the Women's Dignity Project/Utu Mwanamke, PO Box 79402, Dar es Salaam, Tanzania.