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Uwazi Monitoring June 2012 Brief No. 3
What does Dar make of hea  lth? 
Health service and practi  ce in Dar es Salaam
This note was writt  en by Kevin Croke under the
guidance of Rose Aiko, and produced by Uwazi at 
Twaweza housed by Hivos Tanzania.
P.O. Box 38342, Dar es Salaam, Tanzania. 
T : +255 22 266 4301. F: +255 22 266 4308.
Email : uwazi@twaweza.org. 
Website: www.twaweza.org/go/uwazi
Introducti  on
The 2010 Tanzania Demographic and Health Survey (DHS) shows signifi  cant 
improvements in several key health outcomes; for example, a decrease in child 
mortality and an increase in the use of bed nets to prevent malaria. But other 
indicators lag behind. For example, less than 4 in 10 children under 5 years 
receive the proper fi  rst line anti  -malaria treatment (dawa ya mseto; DHS, 2010), 
and the 2010 Service Delivery Indicators (SDI) Survey showed that about one-
quarter of all basic drugs were out of stock in Tanzanian public sector health 
faciliti  es. 
What has been happening to basic health services in Dar es Salaam, Tanzania’s 
largest city, and what do Dar residents think about the health services that they 
use? 
To answer these and other questi  ons, Uwazi at Twaweza conducted a public 
service delivery survey in August and September 2010. A total of 550 randomly 
selected households were visited by the survey team in Ilala, Temeke, and 
Kinondoni districts. The survey asked about citi  zens’ living conditi  ons and their 
experiences with public services. To understand experiences with health services, 
respondents were asked about illnesses in their families, recent experiences with 
health services, and about their atti   tudes and practi  ces relati  ng to preventi  ve 
health practi  ces. This brief presents key fi  ndings from the survey.2
Seven facts about health in Dar es Salaam
Fact 1: Ownership of mosquito nets is nearly universal
Malaria is a major health problem, and a key preventive step that households 
can take is to sleep under a bed net. This is especially important for children 
under 5 years and pregnant women. Distribution of nets and promotion of bed 
net use has been a major priority for the Ministry of Health and Social Welfare in 
Tanzania. The survey found that bed net ownership at household level in Dar es 
Salaam is almost universal; 95 percent of the households reported ownership of 
at least one mosquito net.   
Fact 2: Only half of Dar es Salaam residents boil or treat their drinking water
Some of the water borne diseases such as cholera and typhoid fever that afflict 
Tanzanians can be avoided with simple preventive actions. Few Dar es Salaam 
residents have access to clean drinking water on a regular basis. For example, 
only 9.7 percent of all households have home delivery of water by truck or 
primarily use bottled water for drinking. But even when water is clean at source 
it can be contaminated when stored at home. This makes treating water with 
chlorine or boiling it before drinking an important preventive measure for much 
of the population. Yet only half (54 percent) of all interviewed residents reported 
treating their water. Moreover, this varies dramatically by wealth quintile: 75 
percent of residents in the top wealth quintile treat or boil water, as compared to 
23 percent of those in the lowest quintile. 
Figure 1: Percentage of households that treat or boil drinking water
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 20103
Fact 3: One in 3 households had a sick household member in the week before 
the survey
Sickness is not uncommon in Dar es Salaam households. Thirty-two percent of 
households that were interviewed had at least one member that fell sick in the 
week prior to the survey. About one-third of the time this was a very young child. 
In almost 9 out of 10 cases (86 percent), these sick family members were taken to 
a health facility to receive treatment. 
Figure 2: Presence of a sick household member, one week prior to the survey
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 2010
Fact 4: Poorer households are more likely to visit government health facilities 
In Dar es Salaam there is a wide range of places offering health advice or 
treatment: drug shops or duka la dawa, private clinics and hospitals, government 
dispensaries, health centers, and hospitals. The majority (60 percent) of 
respondents in our survey reported using government facilities when their family 
member was sick. Thirty-seven percent sought care at private facilities, while 3 
percent reported that they sought care at religious or NGO facilities. 
Wealth is a major determinant of where patients go to seek medical care. Figure 
3 shows that 82 percent of the poorest households use government services, 
as compared to just 27 percent of the richest households. The higher the 
household income, the less likely it is that household members will seek services 
from government facilities. Just 16 percent of the poorest quintile use private 
services, as compared to 73 percent of the richest residents of Dar es Salaam. As 
a consequence it is the poor that suffer most when public health care facilities do 
not provide good quality services.4
Figure 3: Choice between public and private health facilities by wealth quintile
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 2010
Fact 5: Private facilities do slightly better on several measures of quality of care, 
and significantly better on patient satisfaction  
Quality of medical care is difficult to evaluate through after-the-fact surveys of 
patients or the family members who accompanied these patients when they 
visited health facilities. However, some idea of quality can be gauged by whether 
patients received basic physical exams during their consultation, whether they 
were given advice about how to treat their illness, and whether in their opinion 
they were treated with respect at the health facility. As Figure 4 shows, there is 
a relatively small difference on each scale of service provided between private 
and public hospitals with respect to the most basic components of a health 
facility visit. On the other hand, 8 in 10 patients are satisfied with the service they 
received from private health facilities, compared to 6 in 10 in patients that report 
satisfaction with public health facilities. 5
Figure 4: Details about health consultation by facility type
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 2010
Fact 6: One-quarter of public health facility visits had over two hours waiting 
time
Why do Dar es Salaam residents report preferring private facilities? One reason 
might be waiting times: service is faster in private sector facilities compared to 
public facilities. Eighty percent of patients were attended to within 30 minutes at 
private facilities, as compared to just 31 percent in public facilities. One-quarter 
reported having to wait for two or more hours in public facilities, and 16 percent 
waited for more than three hours.
Figure 5: Waiting time at health facility, by facility type
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 20106
Fact 7: One in five residents found it necessary to pay a bribe at a public health 
facility 
Another reason why Dar es Salaam residents prefer private facilities (if they can 
afford them) may be due to the prevalence of bribes at public health facilities. 
Almost one in five Dar residents reported that they had paid a bribe to get 
service at a public health facility in the past 12 months. The fact that bribes have 
to be paid may mean that the poorest residents are less able to acquire the 
services they need. 
Figure 6: Respondents who paid a bribe at a public health facility in 
the past year
Source of Data: Uwazi, Public Service Delivery Survey, Dar es Salaam, 20107
Conclusion 
This brief has presented some findings related to preventive health practices 
and use of health services in Dar es Salaam. Our findings suggest that in part, 
government policies (i.e. free distribution of bed nets) have enabled families to 
take preventive health measures. On the other hand, a substantial proportion 
of residents still do not take key preventive measures, such as treating or boiling 
drinking water. Many residents also feel that health services still leave much to 
be desired: it appears that bribery is not uncommon in public health facilities 
and a significant proportion of residents are unsatisfied by the services that they 
receive from these facilities. 
Recent achievements in health in Tanzania may have therefore been reached 
through the easier (‘low-hanging fruit’) interventions, such as distributing free 
mosquito nets. Making further gains is likely to be much harder as it will entail 
addressing aspects of quality of care, including better diagnosis, responsiveness 
to patients, and improvements in drug supply. Such steps should also include 
measures to reduce financial barriers to access and better accountability (e.g. 
dealing with bribery and diversion) in dispensaries, health centers, and hospitals. 
Greater transparency of the conditions of services, resources and entitlements 
may be a good place to start.

\ud
What Does Dar Make of Health?:Health Service and Practice in Dar es Salaam\ud

http://ihi.eprints.org/755/1/twaweza2.pdf

\ud What Does Dar Make of Health?:Health Service and Practice in Dar es Salaam\ud

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