Health inequities occur when health services are not accessible or utilized by certain groups of people, based on their gender, socio-economic status, ethnicity, geographic residence, or another characteristic. For example, in Tanzania, newborn mortality is 67% higher among the poorest families compared to the wealthiest families. In order to improve equity and reduce maternal, newborn, and child mortality, disadvantaged or high risk groups must be targeted for services and interventions.
Tanzania’s National Health Insurance Fund introduced a health insurance card scheme in 2011. The insurance card allows pregnant women to access health services free of charge, with the ultimate goal of increasing utilization of quality maternal services by poor women. In Rungwe district, the program initially used individual targeting, in which women were screened for their level of poverty before receiving a card. Due to challenges with this approach and in light of the fact that the region has a high rate of poverty, the program adopted geographic targeting instead, giving the card to all pregnant women in all districts of the Mbeya region. TRAction supported a case study to investigate perceptions and processes of the targeting approaches, and the factors that influence women’s use of the cards for facility delivery.
Tanzania: Mbeya Region
This case study aimed to investigate the processes and equity outcomes of both individual and geographic targeting of insurance cards. Research questions include:
This study used both qualitative and quantitative methods to understand the impact of both targeting approaches on equity and coverage, and to identify factors influencing use or non-use of insurance cards for delivery.
A review of facility records and patient registers provided quantitative data on the number of insurance cards distributed and used at each site. Coverage and use of the cards by poor women was evaluated.
Qualitative group interviews with district health staff and insurance scheme implementers provided a context for the quantitative data, by investigating the implementation process and perceptions of the targeting approaches. Group interviews with health providers at the hospital, health center, and dispensary levels addressed their experiences with the two targeting approaches, and their observations about what factors influence use of the cards. In-depth interviews were conducted with women who received the insurance card and used it to deliver in a facility, as well as women who received the card but did not use it (delivered at home).
High rates of facility deliveries were achieved after implementation of the program, although women with the lowest educational attainment were underrepresented among those who delivered in facilities. Qualitative findings indicated that a sense of stigmatization, informal payments to village executives, and difficulties in the screening procedure hindered individual targeting efforts. Decision making in favor of geographical targeting took a top down approach. Providers experienced increases in the number of clients after the change to geographical targeting, which led to an increase in work load, but they appreciated the reimbursement mechanisms that ensured greater resources at facility level. Beneficiaries’ awareness of the risks associated with home delivery influenced them to prefer facility delivery.
It is necessary for women to be educated about existing interventions that aim to increase use of health care services. Interventions which aim to increase facility births should also focus on improving the quality of care during delivery and subsequent postnatal care. Despite the fact that the insurance card program had distributed medical equipment in the facilities, it is unclear whether they have been used as planned. Furthermore, increased workload for the staff could impact the quality of work and information generated at the facilities. As such, it is imperative for staff to be well equipped in order to ensure the quality of healthcare services. For those facilities that are understaffed, initiatives should be taken to increase the staff in maternal and child health departments.
This case study identified contextual factors influencing the decision to use insurance cards for health facility-based delivery, and will explain how and why different targeting approaches impact equitable access to care. The results will be shared with the Tanzanian Ministry of Health and Social Welfare, to inform decisions about future targeting approaches in the country. In addition, TRAction will synthesize the findings from this and four other equity studies to gain a global understanding of factors influencing access and utilization of facilities for delivery. Experience from this study and other TRAction projects will inform the development of training materials and other tools for conducting qualitative studies.