Perceived and Real Costs of Antenatal Care Seeking and their Implications For Women’s Access to Intermittent\ud Preventive Treatment of Malaria in Pregnancy in Rural Tanzanian Districts

Debate about the influence of costs of seeking Antenatal Care (ANC) on the maternal health service utilization in Africa has remained controversial and generally inconclusive, calling for more systematic, robust and reliable evidence. A study was done to assess the influence of real and perceived costs of ANC seeking on pregnant women’s access to Intermittent Preventive Treatment in Pregnancy (IPTp) against malaria in two rural districts in Tanzania. Exist interviews were administered to 823 pregnant women leaving ANC clinics, among which 417 and 406 came from Mkuranga and Mufindi districts, respectively. Data analysis was executed using STATA 8 statistical software. Of all interviewees, 66.2% and 89.3% of respondents in Mkuranga and Mufindi, respectively, previously contacted government clinics during their current pregnancies; less than 20% and 15% of these districts, respectively, had contacted private clinics. Respondents reporting to have paid user-fees on the study day accounted for 36.7% and 7.0% in both districts, respectively. Few (<2%) of the respondents in each district reported unofficial payments asked of them by clinic staff for the services sought. In both districts, long travel distance was identified as the main disappointing factor against ANC seeks, followed by health care user-fees. Apparently, perceived low quality of care at particular clinics had more influenced the respondents found in public clinics to visit private clinics than it had influenced those found at private clinics to contact public ones. Respondents from wealthier families and those with decision-making autonomy for spending family income were less likely to have faced user-fee payment hardship than those without such opportunities. Lack of money for user-fees or transport delayed 12.6% and 12.4% of the respondents in Mkuranga and Mufindi, respectively to register for the ANC and receive IPTp during the recommended period. Evidently, real and perceived costs together with perceived quality of care influence rural women to seek ANC and determine their chance to access malaria IPTp in Tanzania

The Tanzanian Policy on Health-Care Fee Waivers and Exemptions in Practice as Compared With Other Developing Countries: Evidence from Recent Local Studies and International Literature

After introducing user charges in government hospitals and the presence of similar charges in the private health sector, the Tanzanian government established a policy for protecting poorest and vulnerable populations from healthcare charges. By citing evidence on similar experience from other developing countries, this paper presents, although in descriptive form, findings from technical research reports based on recent studies in Tanzania and critically analyses the relationship between government policy and its translation into practice. Evidence from previous but recent local studies indicates that while the policy explicitly identifies people with certain medical conditions as vulnerable groups eligible for exemptions, the issue of 'waivers' has been left to be decided at the discretion of local community leaders and health workers on ground that they know better the lifestyles, backgrounds and health conditions of the people surrounding them. This was viewed as a way of decentralizing decisions to local government authorities in granting such mechanisms to eligible people at the existing rates of health-care payments. This policy failure to define 'who are the poor' or how the poor should be assessed has caused confusion among health-care providers in identifying people who are eligible for waivers. It has also been used as a loophole for some health administrators to ignore people who deserve waivers since some people eligible for exemptions or waivers still pay either directly at the counter or indirectly under the table in order to get the better services they need. Other people delay or fail to contact health facilities due to lack of money or by avoiding the institutional bureaucracy in confirming who deserves a waiver. Some people do not benefit from exemptions because of lack of knowledge if they qualify and/or the procedures for presenting their claims. Meanwhile some exemptions are granted to people other than the targeted vulnerable groups. On the other hand, health workers hesitate to approve exemptions and waivers to avoid losing revenue on the side of their health facilities. Additional findings, discussions, conclusionand recommendations are presented

Implementing Intermittent Preventive Treatment for Malaria in Pregnancy: Review of Prospects, Achievements, Challenges and Agenda for Research.

INTRODUCTION: Implementing Intermittent Preventive Treatment for malaria in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) through antenatal care (ANC) clinics is recommended for malaria endemic countries. Vast biomedical literature on malaria prevention focuses more on the epidemiological and cost-effectiveness analyses of the randomised controlled trials carried out in selected geographical settings. Such studies fail to elucidate the economic, psychosocial, managerial, organization and other contextual systemic factors influencing the operational effectiveness, compliance and coverage of the recommended interventions. OBJECTIVE: To review literature on policy advances, achievements, constraints and challenges to malaria IPTp implementation, emphasising on its operational feasibility in the context of health-care financing, provision and uptake, resource constraints and psychosocial factors in Africa. RESULTS: The importance of IPTp in preventing unnecessary anaemia, morbidity and mortality in pregnancy and improving childbirth outcomes is highly acknowledged, although the following factors appear to be the main constraints to IPTp service delivery and uptake: cost of accessing ANC; myths and other discriminatory socio-cultural values on pregnancy; target users, perceptions and attitudes towards SP, malaria, and quality of ANC; supply and cost of SP at health facilities; understaffing and demoralised staff; ambiguity and impracticability of user-fee exemption policy guidelines on essential ANC services; implementing IPTp, bednets, HIV and syphilis screening programmes in the same clinic settings; and reports on increasing parasite resistant to SP. However, the noted increase in the coverage of the delivery of IPTp doses in several countries justify that IPTp implementation is possible and better than not. CONCLUSION: IPTp for malaria is implemented in constrained conditions in Africa. This is a challenge for higher coverage of at least two doses and attainment of the Abuja targets. Yet, there are opportunities for addressing the existing challenges, and one of the useful options is the evaluation of the acceptability and viability of the existing intervention guidelines