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

Determinants of community health fund membership in Tanzania: a mixed methods analysis.

BACKGROUND: In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods. METHODS: A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data. RESULTS: The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment. CONCLUSIONS: Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage

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\u2019 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\u2019s 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

Inequalities in child mortality in ten major African cities

Background: The existence of socio-economic inequalities in child mortality is well documented. African cities grow faster than cities in most other regions of the world; and inequalities in African cities are thought to be particularly large. Revealing health-related inequalities is essential in order for governments to be able to act against them. This study aimed to systematically compare inequalities in child mortality across 10 major African cities (Cairo, Lagos, Kinshasa, Luanda, Abidjan, Dar es Salaam, Nairobi, Dakar, Addis Ababa, Accra), and to investigate trends in such inequalities over time. Methods: Data from two rounds of demographic and health surveys (DHS) were used for this study (if available): one from around the year 2000 and one from between 2007 and 2011. Child mortality rates within cities were calculated by population wealth quintiles. Inequality in child mortality was assessed by computing two measures of relative inequality (the rate ratio and the concentration index) and two measures of absolute inequality (the difference and the Erreyger's index). Results: Mean child mortality rates ranged from about 39 deaths per 1,000 live births in Cairo (2008) to about 107 deaths per 1,000 live births in Dar es Salaam (2010). Significant inequalities were found in Kinshasa, Luanda, Abidjan, and Addis Ababa in the most recent survey. The difference between the poorest quintile and the richest quintile was as much as 108 deaths per 1,000 live births (95% confidence interval 55 to 166) in Abidjan in 2011-2012. When comparing inequalities across cities or over time, confidence intervals of all measures almost always overlap. Nevertheless, inequalities appear to have increased in Abidjan, while they appear to have decreased in Cairo, Lagos, Dar es Salaam, Nairobi and Dakar. Conclusions: Considerable inequalities exist in almost all cities but the level of inequalities and their development over time appear to differ across cities. This implies that inequalities are amenable to policy interventions and that it is worth investigating why inequalities are higher in one city than in another. However, larger samples are needed in order to improve the certainty of our results. Currently available data samples from DHS are too small to reliably quantify the level of inequalities within cities

Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?

Background: Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. Methods: This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. Results: Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20–64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005–2010) for RMNH expenditures (2005–2010) and 165 % for CH expenditures (2005–2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. Conclusions: Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3403-4) contains supplementary material, which is available to authorized users

Predicting Consumption Expenditure for the Analysis of Health Care Financing Equity in Low Income Countries: a Comparison of Approaches

The analysis of equity in the distribution of health care payments requires nationally representative income and expenditure surveys, containing information on health care payments and ability to pay. Such national household surveys in developing countries collect limited information on out-of-pocket payments for health care but comprehensive information on household consumption expenditure (a proxy of income). There are also limited nationally representative health surveys to conduct equity analyses requiring an administration of small health-specific surveys to collect detailed information on health care payments. However, collecting household expenditure is expensive and time . This study compares quantile regression to Ordinary Least Square in predicting consumption expenditure. Split sample method and cross validation tests are used to evaluate the prediction methodology. Unlike OLS, the quantile model does not distort the values of, the Gini index, the concentration index and the Kakwani index and is the preferred method for predicting consumption expenditure for financing incidence analysis

Monitoring and evaluating progress towards Universal Health Coverage in Tanzania.

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Gemini Mtei and colleagues illustrate progress towards UHC and its monitoring and evaluation in Tanzania. Please see later in the article for the Editors' Summary