Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care.

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

A political economy analysis of strengthening health information system in Tanzania.

BACKGROUND: Many countries' health systems are implementing reforms to improve the functioning and performance of the Health Management Information System (HMIS) to facilitate evidence-based decisions for delivery of accessible and quality health services. However, in some countries such efforts and initiatives have led to a complex HMIS ecosystem characterized by multiple and fragmented sub-systems. We undertook an in-depth analysis of the HMIS ecosystem in Tanzania to inform the ongoing initiatives, by understanding the relationship and power differences among stakeholders, as well as drivers and barriers to HMIS investment and strengthening. METHODOLOGY: This was a qualitative research method incorporating data collection through document review and key informant interviews guided by political economy analytical framework. A total of 17 key informant interviews were conducted between April and May 2022. A thematic content analysis was used during data analysis. RESULTS: Good relationship between the government and stakeholders dealing/supporting HMIS ecosystem was noted as there are technical working groups which brings stakeholders together to discuss and harmonize HMIS activities. The 'need for the data' has been the driving force toward investment in the HMIS ecosystem. The analysis showed that the government is the main stakeholder within the HMIS ecosystem and responsible for identifying the needs for improvement and has the power to approve or reject systems which are not in line with the government priority as stipulated with the HMIS investment roadmap/strategy. Moreover, partners with long relationship are powerful in influencing HMIS investment decision-making compared to those who are recently coming to support. It was further noted shortage of staff with technical competence, inadequate financial resources, and the development of fact that some of the existing systems have not been developed to their full capacity and have hindered the whole systems' integration and interoperability exercise of ensuring integration and interoperability of the systems. CONCLUSION: A need-based assessment of staff capacity at the sub-national level is equally important to identify available capabilities and the knowledge gap to strengthen the HMIS ecosystem. Strong coordination of the ideas and resources intended to strengthen the HMIS ecosystem would help to reduce fragmentation. In addition, there is a need to mobilize resources within and outside the country to facilitate the integration and interoperability process smoothly.

Investigating sustainability challenges for the National Health Insurance Fund in Tanzania: a modelling approach.

OBJECTIVE: This study aimed to model the long-term cost associated with expanding public health insurance coverage in Tanzania. DESIGN, SETTING AND PARTICIPANTS: We analysed the 2016 claims of 2 923 524 beneficiaries of the National Health Insurance Fund in Tanzania. The analysis focused on determining the average cost per beneficiary across 5-year age groups separated by gender, and grouped by broad health condition categories. We then modelled three different insurance coverage scenarios from 2020 to 2050 and we estimated the associated costs. OUTCOME MEASURES: Average cost per beneficiary and the projected financing requirements, projected from 2020 to 2050. RESULTS: The analysis revealed that the average per beneficiary cost for insurance claims was $38.58. Among males over 75 years, the average insurance claims costs were highest, amounting to $125. The total estimated annual cost of claims in 2020 was $151 million. Under the status quo coverage scenario, total claims were projected to increase to $415 million by 2050. Increasing coverage from 7% to 50% would result in an additional financing requirement of $2.27 billion. If coverage would increase by 10% annually, reaching 56% of the population by 2050, the additional financing need would amount to $2.84 billion. CONCLUSION: This study highlights the critical importance of assessing the long-term financial viability of health insurance schemes aimed to cover large segments of the population in low-income countries. The findings demonstrate that even without expansion of coverage, financing requirements for insurance will more than triple by 2050. Furthermore, increasing coverage is likely to substantially escalate the cost of claims, potentially requiring significant government or external contributions to finance these additional costs. Policymakers and stakeholders should carefully evaluate the sustainability of insurance schemes to ensure adequate financial support for expanding coverage and improving healthcare access in low-income settings.

Cost Effectiveness of Strategies for Caring for Critically Ill Patients with COVID-19 in Tanzania.

BACKGROUND: The resources for critical care are limited in many settings, exacerbating the significant morbidity and mortality associated with critical illness. Budget constraints can lead to choices between investing in advanced critical care (e.g. mechanical ventilators in intensive care units) or more basic critical care such as Essential Emergency and Critical Care (EECC; e.g. vital signs monitoring, oxygen therapy, and intravenous fluids). METHODS: We investigated the cost effectiveness of providing EECC and advanced critical care in Tanzania in comparison with providing 'no critical care' or 'district hospital-level critical care' using coronavirus disease 2019 (COVID-19) as a tracer condition. We developed an open-source Markov model ( https://github.com/EECCnetwork/POETIC_CEA ) to estimate costs and disability-adjusted life-years (DALYs) averted, using a provider perspective, a 28-day time horizon, patient outcomes obtained from an elicitation method involving a seven-member expert group, a normative costing study, and published literature. We performed a univariate and probabilistic sensitivity analysis to assess the robustness of our results. , RESULTS: EECC is cost effective 94% and 99% of the time when compared with no critical care (incremental cost-effectiveness ratio [ICER] $37 [-$9 to $790] per DALY averted) and district hospital-level critical care (ICER $14 [-$200 to $263] per DALY averted), respectively, relative to the lowest identified estimate of the willingness-to-pay threshold for Tanzania ($101 per DALY averted). Advanced critical care is cost effective 27% and 40% of the time, when compared with the no critical care or district hospital-level critical care scenarios, respectively. CONCLUSION: For settings where there is limited or no critical care delivery, implementation of EECC could be a highly cost-effective investment. It could reduce mortality and morbidity for critically ill COVID-19 patients, and its cost effectiveness falls within the range considered 'highly cost effective'. Further research is needed to explore the potential of EECC to generate even greater benefits and value for money when patients with diagnoses other than COVID-19 are accounted for.

Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.

Resource use, availability and cost in the provision of critical care in Tanzania: a systematic review.

OBJECTIVES: Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania. DESIGN: This is a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: Medline, Embase and Global Health databases were searched covering the period 2010 to 17 November 2020. ELIGIBILITY CRITERIA: We included studies that reported on forms of critical care offered, critical care services offered and/or costs and resources used in the provision of care in Tanzania published from 2010. DATA EXTRACTION AND SYNTHESIS: Quality assessment of the articles and data extraction was done by two independent researchers. The Reference Case for Estimating the Costs of Global Health Services and Interventions was used to assess quality of included studies. A narrative synthesis of extracted data was conducted. Costs were adjusted and reported in 2019 US$ and TZS using the World Bank GDP deflators. RESULTS: A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: intensive care unit (ICU) delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. Paediatric critical care equipment was more scarce than equipment for adults. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (eg, oxygen, personal protective equipment), services and human resources were identified as inputs to specific critical care services in Tanzania. CONCLUSION: There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilisation and costs across specialties and hospitals of different level in low/middle-income countries like Tanzania to inform planning, priority setting and budgeting for critical care services. PROSPERO REGISTRATION NUMBER: CRD42020221923.

Assessment of Strategic Healthcare Purchasing Arrangements and Functions Towards Universal Coverage in Tanzania.

BACKGROUND: Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania. METHODS: We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data. RESULTS: The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates. CONCLUSION: Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania.

Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.

Assessment of equity in healthcare financing and benefits distribution in Tanzania: a cross-sectional study protocol.

INTRODUCTION: Achieving universal health coverage goal by ensuring access to quality health service without financial hardship is a policy target in many countries. Thus, routine assessments of financial risk protection, and equity in financing and service delivery are required in order to track country progress towards realising this universal coverage target. This study aims to undertake a system-wide assessment of equity in health financing and benefits distribution as well as catastrophic and impoverishing health spending by using the recent national survey data in Tanzania. We aim for updated analyses and compare with previous assessments for trend analyses. METHODS AND ANALYSIS: We will use cross-sectional data from the national Household Budget Survey 2017/2018 covering 9463 households and 45 935 individuals cross all 26 regions of mainland Tanzania. These data include information on service utilisation, healthcare payments and consumption expenditure. To assess the distribution of healthcare benefits (and in relation to healthcare need) across population subgroups, we will employ a benefit incidence analysis across public and private health providers. The distributions of healthcare benefits across population subgroups will be summarised by concentration indices. The distribution of healthcare financing burdens in relation to household ability-to-pay across population subgroups will be assessed through a financing incidence analysis. Financing incidence analysis will focus on domestic sources (tax revenues, insurance contributions and out-of-pocket payments). Kakwani indices will be used to summarise the distributions of financing burdens according to households' ability to pay. We will further estimate two measures of financial risk protection (ie, catastrophic health expenditure and impoverishing effect of healthcare payments). ETHICS AND DISSEMINATION: We will involve secondary data analysis that does not require ethical approval. The results of this study will be disseminated through stakeholder meetings, peer-reviewed journal articles, policy briefs, local and international conferences and through social media platforms.

How to bring research evidence into policy? Synthesizing strategies of five research projects in low-and middle-income countries.

BACKGROUND: Addressing the uptake of research findings into policy-making is increasingly important for researchers who ultimately seek to contribute to improved health outcomes. The aims of the Swiss Programme for Research on Global Issues for Development (r4d Programme) initiated by the Swiss National Science Foundation and the Swiss Agency for Development and Cooperation are to create and disseminate knowledge that supports policy changes in the context of the 2030 Agenda for Sustainable Development. This paper reports on five r4d research projects and shows how researchers engage with various stakeholders, including policy-makers, in order to assure uptake of the research results. METHODS: Eleven in-depth interviews were conducted with principal investigators and their research partners from five r4d projects, using a semi-structured interview guide. The interviews explored the process of how stakeholders and policy-makers were engaged in the research project. RESULTS: Three key strategies were identified as fostering research uptake into policies and practices: (S1) stakeholders directly engaged with and sought evidence from researchers; (S2) stakeholders were involved in the design and throughout the implementation of the research project; and (S3) stakeholders engaged in participatory and transdisciplinary research approaches to coproduce knowledge and inform policy. In the first strategy, research evidence was directly taken up by international stakeholders as they were actively seeking new evidence on a very specific topic to up-date international guidelines. In the second strategy, examples from two r4d projects show that collaboration with stakeholders from early on in the projects increased the likelihood of translating research into policy, but that the latter was more effective in a supportive and stable policy environment. The third strategy adopted by two other r4d projects demonstrates the benefits of promoting colearning as a way to address potential power dynamics and working effectively across the local policy landscape through robust research partnerships. CONCLUSIONS: This paper provides insights into the different strategies that facilitate collaboration and communication between stakeholders, including policy-makers, and researchers. However, it remains necessary to increase our understanding of the interests and motivations of the different actors involved in the process of influencing policy, identify clear policy-influencing objectives and provide more institutional support to engage in this complex and time-intensive process.

A network analysis of patient referrals in two district health systems in Tanzania.

Patient referral systems are fragile and overlooked components of the health system in Tanzania. Our study aims at exploring patient referral networks in two rural districts in Tanzania, Kilolo and Msalala. Firstly, we ask whether secondary-level facilities act as gatekeepers, mediating referrals from primary- to tertiary-level facilities. Secondly, we explore the facility and network-level determinants of patient referrals focusing on treatment of childhood illnesses and non-communicable diseases. We use data collected across all public health facilities in the districts in 2018. To study gatekeeping, we employ descriptive network analysis tools. To explore the determinants of referrals, we use exponential random graph models. In Kilolo, we find a disproportionate share of patients referred directly to the largest hospital due to geographical proximity. In Msalala, small and specialized secondary-level facilities seem to attract more patients. Overall, the results call for policies to increase referrals to secondary facilities avoiding expensive referrals to hospitals, improving timeliness of care and reducing travel-related financial burden for households.

Acceptability of a Prime Vendor System in Public Healthcare Facilities in Tanzania.

BACKGROUND: Pharmaceutical supply chain management in low- and middle-income countries has received substantial attention to address the shortage of medicines at peripheral facilities. The focus has been on health system interventions, including the establishment of public-private partnerships (PPPs). In 2014, the United Republic of Tanzania began implementing the Jazia prime vendor system (Jazia PVS) with a contracted private wholesale supplier to complement the national medicines supply chain in public facilities. Few studies have investigated the acceptability of such a prime vendor system. This study analyses factors that contributed to the acceptability of Jazia PVS introduced in Tanzania. We used qualitative analytical methods to study experiences of Jazia PVS implementers in 4 districts in mid-2018. METHODS: Data were drawn from 14 focus group discussions (FGDs), 7 group discussions (GDs) and 30 in-depth interviews (IDIs) with a range of actors involved in Jazia PVS. The study analysed 7 acceptability dimensions as defined in the acceptability framework by Sekhon et al. Framework analysis was adopted to summarise the results using a deductive and an inductive approach. RESULTS: The findings show that participants' acceptability of Jazia PVS was influenced by the increased availability of essential medicines at the facilities, higher order fulfilment rates, and timely delivery of the consignment. Furthermore, acceptability was also influenced by the good reputation of the prime vendor, close collaboration with district managers, and participants' understanding that the prime vendor was meant to complement the existing supply chain. Intervention coherence, experienced opportunity cost and intervention burden, affective attitude and self-efficacy were also important in explaining the acceptability of the Jazia PVS. CONCLUSION: In conclusion, the most critical factor contributing to the acceptability of the Jazia PVS was the perceived effectiveness of the system in achieving its intended purpose. Districts purchasing directly from the prime vendor have a policy based on the possibility to increase availability of essential medicines at peripheral facilities in a low income setting; however, it is crucial to select a reputable and competent vendor, as well as to abide by the contractual agreements.

Cost and cost drivers associated with setting-up a prime vendor system to complement the national medicines supply chain in Tanzania.

INTRODUCTION: Economic analysis of supply chain management interventions to improve the availability of healthcare commodities at healthcare facilities is important in generating evidence for decision-makers. The current study assesses the cost and cost drivers for setting-up a public-private partnership programme in Tanzania in which all public healthcare facility orders for complementary medicines are pooled at the district level, and then purchased from one contracted supplier, the prime vendor (referred to as 'Jazia Prime Vendor System' (Jazia PVS)). METHODS: Financial and economic costs of Jazia PVS were collected retrospectively and using the ingredients approach. The financial costs were spread over the implementation period of January 2014-July 2019. In addition, we estimated the financial rollout costs of Jazia PVS to the other 23 regions in the country over 2 years (2018-2019). A multivariate sensitivity analysis was conducted on the estimates. RESULTS: Jazia PVS start-up and recurrent financial costs amounted to US$2 170 989.74 and US$709 302.32, respectively. The main cost drivers were costs for short-term experts, training of staff and healthcare workers and the Jazia PVS technical and board management activities. The start-up financial cost per facility was US$2819.47 and cost per capita was US$0.37. CONCLUSION: In conclusion, the study provides useful information on the cost and cost drivers for setting-up a complementary pharmaceutical supply system to complement an existing system in low-income settings. Despite the substantial costs incurred in the initial investment and operations of the Jazia PVS, the new framework is effective in achieving the desired purpose of improving availability of healthcare commodities.

The role of accountability in the performance of Jazia prime vendor system in Tanzania.

BACKGROUND: Access to safe, effective, quality and affordable essential medicines for all is a central component of Universal Health Coverage (UHC). However, the availability of quality medicines in peripheral healthcare facilities is often limited. Several countries have developed integrated complementary pharmaceutical supply systems to address the shortage of medicines. Nevertheless, there is little evidence on how accountability contributes to the performance of such complementary pharmaceutical supply systems in low-income settings. The current study analyses how accountability mechanisms contributed to the performance of Jazia Prime Vendor System (Jazia PVS) in Tanzania. METHODS: The study analysed financial, performance and procedure accountability as defined in Boven's accountability framework. We conducted 30 in-depth interviews (IDIs), seven group discussions (GD) and 14 focus group discussions (FGDs) in 2018 in four districts that implemented Jazia PVS. We used a deductive and inductive approach to develop the themes and framework analysis to summarize the data. RESULTS: The study findings revealed that a number of accountability mechanisms implemented in conjunction with Jazia PVS contributed to the performance of Jazia PVS. These include inventory and financial auditing conducted by district pharmacists and the internal auditors, close monitoring of standard operating procedures by the prime vendor regional coordinating office and peer cascade coaching. Furthermore, the auditing activities allowed identifying challenges of delayed payment to the vendor and possible approaches for mitigation while peer cascade coaching played a crucial role in enabling staff at the primary facilities to improve skills to oversee and manage the medicines supply chain. CONCLUSION: Financial, performance and procedure accountability measures played an important role for the successful performance of Jazia PVS in Tanzania. The study highlights the need for capacity building linked to financial and supply management at lower level health facilities, including health facility governing committees, which are responsible for priority-setting and decision-making at facility level.

The effects of medicines availability and stock-outs on household's utilization of healthcare services in Dodoma region, Tanzania.

Low- and middle-income countries have been undertaking health finance reforms to address shortages of medicines. However, data are lacking on how medicine availability and stock-outs influence access to health services in Tanzania. The current study assesses the effects of medicine availability and stock-outs on healthcare utilization in Dodoma region, Tanzania. We conducted a cross-sectional study that combined information from households and healthcare facility surveys. A total of 4 hospitals and 89 public primary health facilities were surveyed. The facility surveys included observation, record review over a 3-month period prior to survey date, and interviews with key staff. In addition, 1237 households within the health facility catchment areas were interviewed. Data from the facility survey were linked with data from the household survey. Descriptive analysis and multivariate logistic regressions models were used to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Eighteen medicines were selected as 'tracers' to assess availability more generally, and these were continuously available in ∼70% of the time in facilities across all districts over 3 months of review. The main analysis showed that household's healthcare utilization was positively and significantly associated with continuous availability of all essential medicines for the surveyed facilities [odds ratio (OR) 3.49, 95% confidence interval (CI) 1.02-12.04; P = 0.047]. Healthcare utilization was positively associated with household membership in the community health insurance funds (OR 1.97, 95% CI 1.23-3.17; P = 0.005) and exposure to healthcare education (OR 2.75, 95% CI 1.84-4.08; P = 0.000). These results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services.

Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation.

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes. Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers. Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.

Bank accounts for public primary health care facilities: Reflections on implementation from three districts in Tanzania.

Health care financing reforms are gaining popularity in a number of African countries to increase financial resources and promote financial autonomy, particularly at peripheral health care facilities. The paper explores the establishment of facility bank accounts at public primary facilities in Tanzania, with the intention of informing other countries embarking on such reform of the lessons learned from its implementation process. A case study approach was used, in which three district councils were purposively sampled. A total of 34 focus group discussions and 14 in-depth interviews were conducted. Thematic content analysis was used during analysis. The study revealed that the main use of bank account revenue was for the purchase of drugs, medical supplies, and minor facility needs. To ensure accountability for funds, health care facilities had to submit monthly reports of expenditures incurred. District managers also undertook quality control of facility infrastructure, which had been renovated using facility resources and purchases of facility needs. Facility autonomy in the use of revenue retained in their accounts would improve the availability of drugs and service delivery. The experienced process of opening facility bank accounts, managing, and using the funds highlights the need to strengthen the capacity of staff and health-governing committees.

Eye of the beholder? Observation versus self-report in the measurement of disrespect and abuse during facility-based childbirth.

Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also develop a deeper, more nuanced understanding of how power operates in health systems under particular social, cultural and political conditions, if they are to effectively challenge settled patterns of behaviour and health systems structures that marginalise and abuse. In this paper, we report results from a mixed methods study in two hospitals in the Tanga region of Tanzania, comparing the prevalence of disrespect and abuse during childbirth as measured through observation by trained nurses stationed in maternity wards to prevalence as measured by the self-report upon discharge of the same women who had been observed. The huge disparity between these two measures (baseline: 69.83% observation vs. 9.91% self-report; endline: 32.91% observation vs. 7.59% self-report) suggests that disrespect and abuse is both internalised and normalised by users and providers alike. Building on qualitative research conducted in the study sites, we explore the mechanisms by which hidden and invisible power enforces internalisation and normalisation, and describe the implications for the development of HRBAs in maternal health.

An assessment of equity in the distribution of non-financial health care inputs across public primary health care facilities in Tanzania.

BACKGROUND: There is limited evidence on how health care inputs are distributed from the sub-national level down to health facilities and their potential influence on promoting health equity. To address this gap, this paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. METHODS: This is a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. We administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. A total of seventeen indices of input availability were constructed with the collected data. The distribution of inputs was considered in relation to (i) the wealth of patients accessing the facilities, which was taken as a proxy for the wealth of the population in the catchment area; and (ii) facility distance from the district headquarters. We assessed equity in the distribution of inputs through the use of equity ratios, concentration indices and curves. RESULTS: We found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. CONCLUSION: This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.

The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis.

BACKGROUND: Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services. METHODS: A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries' education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women's decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants. RESULTS: Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home. CONCLUSIONS: To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as giving women insurance cards only does not guarantee facility-based delivery.