Payments and Quality of Ante-Natal Care in Two Rural Districts of Tanzania

This paper surveys women’s experiences with payments for ante-natal care (ANC) and associated issues of quality in two rural districts of Tanzania. We draw on quantitative and qualitative data from interviews in facilities and in households in the two districts to explore these issues, and discuss some policy implications. The paper provides evidence of payments for ANC in the two rural districts. Striking differences in payments between the two districts were observed, apparently reflecting variation in charging practices in different parts of the districts. In the areas surveyed in one district, women were paying little, in both faith-based organisations (FBOs) and in the public sector. In the other district, charges were much higher in facilities that women had attended, including a district hospital and a public dispensary that seemed to have gone into business on its own account. We explore to what extent these higher charges were associated with better-quality care: The women in the higher-charging district had in general received somewhat higher levels of service than the women interviewed in the lower-charging district, with the notable exception of a low-charging FBO-owned hospital that was succeeding in combining low and predictable charges with good services. In both districts, we found few reports of abuse at the ANC level – this appears to be more a problem at birth. The main quality issues at this level are lack of basic ANC services in some of the public health facilities, and having to pay for ANC even in some of the public facilities where these services are supposed to be provided for free. However, the problem of supply shortages seems to have generated a system of informal charging in some contexts. Sale of assets and borrowing to pay for ANC means impoverishment in order to access a payment-exempted service. We also found that health insurance appears to be creating or supporting a culture of charging for ANC. ANC accessible to all women is a key requirement for improved maternal survival. The findings discussed in this paper suggest the need for a more concerted effort to implement effectively strategies that are already in place, and to come up with other alternative strategies that may result into better outcomes. Such strategies should not be considered in isolation, but should be part of effective strategies to improve all aspects of maternal health. Furthermore, an emerging problem needs to be looked into, and appropriate action taken. Health insurance, which is intended to promote access to health care for the poor, seems in this case to be creating a contrary effect by exacerbating the problem of payments for services that should be exempted from payment.\u

HIV/AIDS/STI Surveillance Report:Report Number 21

Since the first cases of Acquired Immunodeficiency Syndrome (AIDS) in Tanzania were reported in 1983, the epidemic has evolved from being a rare and new disease to a common household problem, which has affected most Tanzania families. The mainland Tanzania faces a generalized human immunodeficiency virus (HIV) and AIDS epidemic, with an estimated 6.5% of the mainland population infected with HIV (7.7% of adult women and 6.3% of adult men). Overall, 1.4 million Tanzanians (1,300,000 adults and 110,000 children) are living with HIV infection, in a total population of 41 million. The social, economic, and environmental impact of the pandemic is sorely felt as an estimated 140,000 Tanzanians have perished, leaving behind as estimated 2.5 million orphans and vulnerable children, representing approximately 10-12% of all Tanzanian children. As elsewhere in sub-Saharan African, the underlying factors of poverty, migration, marginalization, lack of information and skills, disempowerment, and poor access to services raise the risk of HIV and have an impact on the course and spread of the pandemic. Close to 85% of HIV transmission in Tanzania occurs through heterosexual contact, less than 6% through mother-to-child transmission, and less than 1% through blood transfusion. There continues to be a significant difference in the prevalence among urban (10.9%) and rural (5.3%) areas of the country. The National AIDS Control Programme (NACP) of Tanzania was founded in 1987 to champion the health sector response to the HIV epidemic. The primary objectives of the program were to reduce spread of HIV infection, screen blood supplies, enhance clinical services for HIV/AIDS patients and improve STI treatment, prevention of mother-to-child transmission (PMTCT), advocate behavioral change and conduct epidemiologic surveillance and other research. The program phases started with a two-year phase called Short Term Plan\ud (1985-1986). Subsequent phases were termed Medium Term Plans lasting for five-year periods. Through these program phases successful national responses have been identified, the most effective ones being those touching on the major determinants of the epidemic and addressing priority areas that make people vulnerable to HIV infection. These include the following; Since early eighties great efforts have been made to reduce spread of HIV infection through screening of donor blood, advocating behavioral change, condom promotion and improvement of STI treatment. In addition a number of epidemiologic surveillance have been conducted to monitor the trend of HIV infection among different subpopulations e.g. blood donors and pregnant women attending antenatal clinics. In 2004, the National Blood Transfusions Services (NBTS), which is a centralized system of coordinated blood transfusion services, was established. The NBTS is responsible for collection, processing, storage and distribution of safe blood and blood products to health facilities. At the moment NBTS coordinates eight zonal blood transfusion centers, namely Lake Zone-(LZBTC) in Mwanza region, Western-(WZBTC) in Tabora, Northern (NZBTC) in Kilimanjaro region, Eastern (EZBTC) in Dar es Salaam, Southern highlands (SHZBTC) in Mbeya, Southern (SZBTC) in Mtwara and Zanzibar and a military zone –Tanzania People’s Defence Force (TPDF). Since the establishment of NBTS, donated blood in the eight zones is systematically screened for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis. The National HIV Care and Treatment Plan (NCTP) was launched in October 2004, with the main focus of a rapid scaling up of HIV care and treatment services, aimed at having more than 400,000 patients on care and treatment by the end of 2008 and, at the same time, follow up disease progression in 1.2 million HIV+ persons who are not eligible for ntiretroviral therapy (ART). Prevention of Mother to Child Transmission of HIV (PMTCT) services were established in 2002 , providing a package of services that include: counseling and testing for pregnant women; short-course preventive ARV regimens to prevent mother-to-child transmission; counseling and support for safe\ud infant feeding practices; family planning counseling or referral; and referral for long-term ART for the\ud child. This report which covers the NACP activities through December 2008 has been arranged in five chapters and is intended for various stakeholders, primarily those working within the health sector.\u

Acceptability of Condom Promotion and Distribution Among 10-19 Year-Old Adolescents in Mpwapwa and Mbeya Rural Districts, Tanzania.

\ud The HIV/AIDS pandemic remains a leading challenge for global health. Although condoms are acknowledged for their key role on preventing HIV transmission, low and inappropriate use of condoms persists in Tanzania and elsewhere in Africa. This study assesses factors affecting acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural districts of Tanzania. Data were collected in 2011 as part of a larger cross-sectional survey on condom use among 10-19 year-olds in Mpwapwa and Mbeya rural districts of Tanzania using a structured questionnaire. Associations between acceptability of condom promotion and distribution and each of the explanatory variables were tested using Chi Square. Multivariate logistic regression model was used to examine independent predictors of the acceptability of condom promotion and distribution using STATA (11) statistical software at 5% significance level. Mean age of the 1,327 adolescent participants (50.5% being males) was 13.5 years (SD = 1.4). Acceptance of condom promotion and distribution was found among 37% (35% in Mpwapwa and 39% in Mbeya rural) of the adolescents. Being sexually active and aged 15-19 was the strongest predictor of the acceptability of condom promotion and distribution (OR = 7.78, 95% CI 4.65-12.99). Others were; not agreeing that a condom is effective in preventing transmissions of STIs including HIV (OR = 0.34, 95% CI 0.20-0.56), being a resident of Mbeya rural district (OR = 1.67, 95% CI 1.28-2.19), feeling comfortable being seen by parents/guardians holding/buying condoms (OR = 2.20, 95% CI 1.40-3.46) and living with a guardian (OR = 1.48, 95% CI 1.08-2.04). Acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural is low. Effect of sexual activity on the acceptability of condom promotion and distribution is age-dependent and was the strongest. Feeling comfortable being seen by parents/guardians buying or holding condoms, perceived ability of condoms to offer protection against HIV/AIDS infections, district of residence and living arrangements also offered significant predictive effect. Knowledge of these factors is vital in designing successful and sustainable condom promotion and distribution programs in Tanzania.\u

MOESM2 of Determinants of demand for condoms to prevent HIV infections among barmaids and guesthouse workers in two districts, Tanzania

Additional file 2. A Structured Questionnaire for Data Collection from Condom Retailers on Determinants of the Demand for Condoms in Mpwapwa and Mbeya Rural Districts, Tanzania