Inclusion of Persons with Disabilities in the Health Financing System in Tanzania

This report assesses the potential barriers and obstacles that people with disabilities might face when accessing health care services. It is the overall objective of this study to provide evidence on obstacles and financial barriers that people with disabilities might face when accessing health care services in Tanzania. The study presents data of a household surveys with a total amount of 1,480 participants as well as evidence from in-depth interviews and Focus Group Discussions (FGDs) which have been conducted in two selected regions in Tanzania: Tanga and Lindi. The report summarizes these findings and provides evidence on the financing gap in terms of both direct and indirect costs. In order to overcome the many barriers that this report identifies, recommendations on how the gap can be addressed. The relationship between disability and ill-health is complex and need not necessarily result in negative health outcomes for persons with disabilities. This section provides some information on how to define disability. The World Report on Disability (WRD), which was jointly published by the World Bank and the World Health Organization (WHO), notes that disability is associated with a diverse range of primary health conditions of which may result in poor health and high health care needs. Furthermore, the reciprocal relationship ill-health, poverty and vulnerability is emphasized in this chapter.The cross-sectional study at hand employs both quantitative and qualitative research methods. As for the quantitative household survey, 1,480 participants, who were divided into treatment group (households with people with disabilities) and control group (households without people with disabilities), were interviewed in two regions: Tanga and Lindi. The differentiation in these two groups allows to statistically compare whether people with disabilities experience significantly higher barriers to access health care services compared to people without disabilities (instead of just having occurred by chance). Both areas were selected in order to obtain a broader picture in both, rural and urban areas. Furthermore, ethnographic approaches such as in-depth interviews and Focus Group Discussions (FGDs) were used in triangulation, incorporating the advantages of each research approach. The findings of the report suggest that persons with disabilities experience worse socio-economic outcomes and are more prone to poverty than persons without disabilities. Since people with disabilities have lower educational achievements, participate less in the economy and have higher rates of poverty than people without disabilities, they also have a higher risk of poorer health outcomes. Furthermore, the findings of this report show that people with disabilities seldom access health care facilities for either routine or specialised health care services. Only 21 % of the respondents went for routine care within the past three months. The majority of those who went to seek medical assistance went to public health facilities at primary level. Health care seekers reported being overall satisfied with the services and the waiting time. Also, the respondents reported that health service providers tried to establish a trustworthy environment where they treated them in privacy. Those people with disabilities who accessed health services mainly paid the services out of their pocket or through their insurance scheme. Only few people paid the services with other means of informal payment. Additionally, the findings of the report with regards to costs are presented. Costs for medical care can be broken down into three broader categories: (1) Direct Medical Care Costs, (2) Direct Non-Medical Care Costs, (3) Indirect Costs. Overall, 97.4% of the respondents reported to have incurred direct medical costs in both districts. There were more respondents who incurred medical costs for specialised health care in Nachingwea 63.1% as compared to Tanga municipality 47.3%. In terms of indirect costs, 67% of respondents reported that they had to pay for transportation and almost 40 % indicated their consumable costs. In terms of indirect costs, participants reported that they encounter losses of productivity due to the necessity to access health care services (10 days on overage per three months, mean average income lost in Nachingwea and Tanga were Tshs.45,580 (29US$) and Tshs.20,178 (13US$) respectively). Notably, people with disabilities seem to have lower costs for outpatient services than others. This might be due to the fact that many people with disabilities are exempted at dispensary and health center level, though there were complains about the intransparency and malfunctioning of the exemption/waiver-policy in general. In addition, costs for inpatient services (provided at health center and hospital level) for people living with disabilities are almost double the average costs of the control group. (Tshs.77,438 vs Tshs. 41,938). In terms of access to social health protection, few people reported actually using health insurance schemes. Only 12.8 % of the respondents reported to have access to social security related to specialized health care services. Many participants reported that there is not enough information for people with disabilities on insurance schemes and that waiving policies for exempting poor and vulnerable people are inconclusive. More, lack of money seems to be the decisive factor of why people with disabilities are not able to access health care services (72 % reported missing routine health care services and 62 % for specialised health services due to constraint financial resources). Social and communal network are considered particularly important in supporting people with disabilities in accessing health care services. Last but not least, people with disabilities reported a number of unmet needs, including the lack of various services like rehabilitation, counselling services and vocational trainings to improve their productivity. The discussion part of the study contextualises the findings. It reiterates the reciprocal link of poverty and disability and tries to find answers of why people with disabilities hardly access health care services. It further outlines the importance of making health care services available to all, in order to ensure the well-being of people with disabilities. In order to promote the utilization of health care services for people with disability, it further suggests to consider the health care user‟s own perceptions [1]. Despite efforts made by the Ministry of Heath to deliver health care services to the people, most of health care services are still inaccessible to the majority of people with disability. Hence, this study provides a number of recommends with regards to Policy and Legislation, Financing and Affordability, Accessibility and Communit

High risk of maternal death in Southern Tanzania

Reduction of maternal deaths1 is one of the main goals of the Tanzanian Poverty Reduction Strategy and the health sector reform program, but progress has been slow. According to the 1996, 2004 and 2010 Demographic and Health Surveys (DHS), the maternal mortality ratios(MMR) or maternal deaths per 100,000 live births were529, 578, and 454 per 100,000 live births respectively for the 10-year period prior to the surveys [1, 2].Maternal mortality levels by age, education or wealth often reveal major inequities, highlighting the need to reach the most vulnerable. But such information is not available from national surveys because the DHS applies the ‘‘sisterhood method’’, an indirect technique used\ud to estimate maternal mortality (see box). We assessed maternal mortality in a large household census including all 225,000 households in five districts, giving timely mortality data by relative wealth, educational levels and distance to the nearest health facility\ud \ud We used information collected during a 2007 household survey of all households in five districts of Tandahimba and Newala in Mtwara Region and Lindi Rural, Ruangwa and Nachingwea in Lindi Region [5, 6]. A questionnaire recorded all household members and information on age and education. Also, household assets, including possession of a bed net, bicycle or phone, the type of roofing, cooking power and others, were recorded as proxy indicators of household socioeconomic status. In addition, the geographic location was recorded and used to calculate distance to the nearest hospital. Live births in the three years before the survey were recorded through interviews with women of reproductive age (13–49 years).\u

When Incentives Work too well: Locally Implemented Pay for Performance (P4P) and Adverse Sanctions towards Home Birth in Tanzania - A Qualitative Study.

Despite limited evidence of its effectiveness, performance-based payments (P4P) are seen by leading policymakers as a potential solution to the slow progress in reaching Millennium Development Goal 5: improved maternal health. This paper offers insights into two of the aspects that are lacking in the current literature on P4P, namely what strategies health workers employ to reach set targets, and how the intervention plays out when implemented by local government as part of a national programme that does not receive donor funding. A total of 28 in-depth interviews (IDIs) with 25 individuals were conducted in Mvomero district over a period of 15 months in 2010 and 2011, both before and after P4P payments. Seven facilities, including six dispensaries and one health centre, were covered. Informants included 17 nurses, three clinical officers, two medical attendants, one lab technician and two district health administrators. Health workers reported a number of strategies to increase the number of deliveries at their facility, including health education and cooperation with traditional health providers. The staff at all facilities also reported that they had told the women that they would be sanctioned if they gave birth at home, such as being fined or denied clinical cards and/or vaccinations for their babies. There is a great uncertainty in relation to the potential health impacts of the behavioural changes that have come with P4P, as the reported strategies may increase the numbers, but not necessarily the quality. Contrary to the design of the P4P programme, payments were not based on performance. We argue that this was due in part to a lack of resources within the District Administration, and in part as a result of egalitarian fairness principles. Our results suggest that particular attention should be paid to adverse effects when using external rewards for improved health outcomes, and secondly, that P4P may take on a different form when implemented by local implementers without the assistance of professional P4P specialists