Implementing demand side targeting mechanisms for maternal and child health-experiences from national health insurance fund program in Rungwe District, Tanzania

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Study Justification:
– The study aimed to explore the experiences of implementers and decision-makers with targeting mechanisms for maternal and child health care services in Rungwe District, Tanzania.
– The study aimed to understand the impact of targeting mechanisms on equity in access and use of maternal health care services.
– The study aimed to provide insights into the design and implementation of targeting mechanisms to increase program efficiency in reaching marginalized communities.
Study Highlights:
– The study found that the process of screening and identifying poor pregnant women resulted in delays in implementing the intervention.
– Individual targeting was perceived to have stigmatization, leading to beneficiaries not wanting to be identified as poor.
– Geographical targeting increased the number of women accessing higher levels of care, facility revenue, and insurance coverage.
– The study concluded that targeting mechanisms are useful in increasing access and use of health care services for marginalized communities when well designed and involving all stakeholders from the beginning.
Study Recommendations:
– Implement interventions using targeting mechanisms to reach poor people, but ensure they are well designed and involve beneficiaries, implementers, and decision-makers from the start.
– Combine demand-side financing strategies with supply-side interventions to achieve project objectives.
Key Role Players:
– National Health Insurance Fund (NHIF)
– GFA consultant
– Regional Medical Office
– NHIF/CHF coordinators
– Council Health Management team
– Health care providers
Cost Items for Planning Recommendations:
– Training and capacity building for implementers and decision-makers
– Development and implementation of targeting mechanisms
– Monitoring and evaluation of the interventions
– Communication and awareness campaigns for beneficiaries
– Administrative and logistical support for implementation

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used a case study approach and conducted in-depth interviews and group discussions with implementers at various levels. The thematic analysis approach was adopted for data analysis. However, the sample size is relatively small with only 10 in-depth interviews and 4 group discussions. To improve the strength of the evidence, the study could have included a larger sample size and conducted interviews with a more diverse range of stakeholders. Additionally, the study could have used a mixed methods approach to gather both qualitative and quantitative data for a more comprehensive analysis.

Background: Low and middle income countries have adopted targeting mechanisms as a means of increasing program efficiency in reaching marginalized people in the community given the available resources. Design of targeting mechanisms has been changing over time and it is important to understand implementers’ experience with such targeting mechanisms since such mechanisms impact equity in access and use of maternal health care services. Methods: The case study approach was considered as appropriate method for exploring implementers’ and decision-makers’ experiences with the two targeting mechanisms. In-depth interviews in order to explore implementer experience with the two targeting mechanisms. A total of 10 in-depth interviews (IDI) and 4 group discussions (GDs) were conducted with implementers at national level, regional, district and health care facility level. A thematic analysis approach was adopted during data analysis. Results: The whole process of screening and identifying poor pregnant women resulted in delay in implementation of the intervention. Individual targeting was perceived to have some form of stigmatization; hence beneficiaries did not like to be termed as poor. Geographical targeting had a few cons as health care providers experienced an increase in workload while staff remained the same and poor quality of information in the claim forms. However geographical targeting increase in the number of women going to higher level of care (district/regional referral hospital), increase in facility revenue and insurance coverage. Conclusion: Interventions which are using targeting mechanisms to reach poor people are useful in increasing access and use of health care services for marginalized communities so long as they are well designed and beneficiaries as well as all implementers and decision makers are involved from the very beginning. Implementation of demand side financing strategies using targeting mechanisms should go together with supply side interventions in order to achieve project objectives.

The study was conducted in Rungwe district in Mbeya Region. According to a 2012 census the district has a population of about 339,157 (male 161,249 and 177,908 female) [18]. The population density is high in Rungwe district (153 compared to the national average 51 people per square kilometre) and the main economic activity is agriculture [18]. Out of 10 district councils in Mbeya, Rungwe was the only district that had implemented the intervention using the two targeting mechanisms (individual and geographical targeting), while the other districts had adopted a geographical targeting mechanism. It thus offered not only the opportunity to describe the implementer’s experiences with the current geographic targeting strategy, but also to explore the implementer’s attitudes toward both strategies and the reasons for abandoning individual targeting. The study adopted case study methodology, an empirical inquiry that investigates a phenomenon within its real life context [19]. Implementation of maternal and child health care using targeting mechanisms is a complex, context dependent process. The case study approach was thus considered the appropriate method for exploring implementers’ and decision-makers’ experiences with the two targeting mechanisms. The study used in-depth interviews in order to explore implementer experience with the two targeting mechanisms. Because the implementation of the MCH insurance card program involved stakeholders at the national level (NHIF and GFA consultant), regional level (NHIF zone office, Regional medical Office), and district level (NHIF/CHF coordinators, and Council Health Management team), as well as health care providers, it was necessary to collect data at all these levels. Study participants were purposively selected from public health care facilities, district and regional level health authorities, and NHIF headquarters (Table ​(Table1).1). The health system in Tanzania assumes a pyramidal pattern of a referral system starting from village health service which is the lowest level of health care delivery in the country followed by dispensary services which cater for between 6000 and 10,000 people and supervise all the village health posts in its ward. Next level of care is the health centre which is expected to cater for 50,000 people, followed by district hospitals, regional hospitals and lastly referral/consultant hospitals. Ongoing health care financing reforms intends to increase access and use of health care services to the people by building a dispensary in every village and a health centre in every ward [20]. Rungwe district had only one district hospital and two public health centres. All of them were included in the study and four dispensaries were selected based on physical accessibility, experience with the targeting mechanisms, and being served by a health centre. Thus, a total of 7 health care facilities were included in the study. In total, 10 in-depth interviews (IDI) and 4 group discussions (GDs) were carried out by 2 research scientists and 2 field assistants in September 2014 (Table ​(Table11). Qualitative interview sampling for data collection Interview guides were developed and contained a range of topics related to the experience with individual targeting, decision to change, experience with geographical targeting, and recommendations about targeting mechanisms. Interview guides were prepared in English and subsequently translated into Kiswahili by the bi-lingual research scientists and research assistants, who also conducted the interviews. Interviews were conducted in pairs: one research scientist facilitated the interview while a field assistant was taking notes. All interviews were also digitally recorded, and the audio files were transcribed and translated by a research assistant. Subsequently, the researchers cross-checked the audio files and transcripts for data quality assurance. A thematic analysis approach was adopted. Two research scientists read each transcript independently and developed a final code book. A brief discussion was held by the researchers and to determine the final themes. The team worked together and coded a few transcripts together. The remainder were coded independently by each of the research scientists. At the end the team reconvened and discussed the coded scripts. Data were analyzed using Nvivo 10 software.

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders for prenatal care appointments and educational messages, can help improve access to maternal health information and services, especially in remote areas.

2. Community Health Workers (CHWs): Training and deploying community health workers who can provide basic maternal health services, education, and referrals in underserved areas can help improve access to care.

3. Telemedicine: Using telemedicine platforms to connect pregnant women in remote areas with healthcare providers can help overcome geographical barriers and ensure timely access to prenatal care and consultations.

4. Cash Transfer Programs: Implementing cash transfer programs that specifically target pregnant women and provide financial support for accessing maternal health services can help reduce financial barriers and improve access to care.

5. Public-Private Partnerships: Collaborating with private healthcare providers to expand access to maternal health services, especially in areas with limited public healthcare facilities, can help increase the availability of services.

6. Maternal Health Vouchers: Introducing voucher programs that provide pregnant women with subsidized or free access to maternal health services can help overcome financial barriers and increase utilization of services.

7. Transportation Support: Providing transportation support, such as vouchers or shuttle services, for pregnant women in remote areas can help overcome geographical barriers and ensure timely access to healthcare facilities.

8. Maternal Health Education Programs: Implementing comprehensive maternal health education programs that target both women and their families can help increase awareness about the importance of prenatal care and encourage early and regular healthcare-seeking behavior.

9. Task Shifting: Training and empowering lower-level healthcare providers, such as nurses and midwives, to provide a wider range of maternal health services can help address workforce shortages and improve access to care.

10. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities, such as improving infrastructure, ensuring availability of essential supplies and medications, and enhancing provider skills, can help increase the utilization of maternal health services by improving the overall quality of care.

It is important to note that the specific context and needs of the community should be considered when implementing these innovations to ensure their effectiveness and sustainability.
AI Innovations Description
The recommendation from the study is to implement demand side targeting mechanisms for maternal and child health in order to improve access to maternal health care services. The study found that targeting mechanisms, such as individual and geographical targeting, can be effective in reaching marginalized communities and increasing access to health care services. However, it is important to design these targeting mechanisms carefully and involve all stakeholders, including beneficiaries, implementers, and decision-makers, from the beginning.

The study also highlighted some challenges and considerations when implementing targeting mechanisms. For example, the process of screening and identifying poor pregnant women can result in delays in implementing the intervention. Individual targeting was perceived to have some form of stigmatization, which discouraged beneficiaries from participating. Geographical targeting, on the other hand, increased the workload for health care providers and had issues with poor quality of information in claim forms. However, geographical targeting also led to an increase in the number of women accessing higher levels of care, an increase in facility revenue, and improved insurance coverage.

In conclusion, the study recommends that interventions using targeting mechanisms should be accompanied by supply side interventions to achieve project objectives. It is important to involve all stakeholders in the design and implementation of targeting mechanisms to ensure their effectiveness and equity in access to maternal health care services.
AI Innovations Methodology
Based on the provided information, the study conducted in Rungwe District, Tanzania explored the experiences of implementers and decision-makers with targeting mechanisms for maternal and child health. The study used a case study methodology, which involved in-depth interviews and group discussions with implementers at various levels, including national, regional, district, and health care facility level. The data collected was analyzed using a thematic analysis approach.

The study found that the process of screening and identifying poor pregnant women resulted in a delay in implementing the intervention. Individual targeting was perceived to have some form of stigmatization, while geographical targeting had some drawbacks such as an increase in workload for health care providers and poor quality of information in claim forms. However, geographical targeting led to an increase in the number of women accessing higher levels of care, facility revenue, and insurance coverage.

The study concluded that interventions using targeting mechanisms to reach marginalized communities can be effective in increasing access and use of health care services, as long as they are well-designed and involve all stakeholders from the beginning. It also highlighted the importance of combining demand-side financing strategies with supply-side interventions to achieve project objectives.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could involve conducting a pilot study in a similar setting to Rungwe District. The pilot study could involve implementing the targeting mechanisms recommended in the study, such as geographical targeting, and monitoring the outcomes. Data could be collected on indicators such as the number of women accessing maternal health care services, facility revenue, and insurance coverage. This data could then be compared to baseline data to assess the impact of the recommendations on improving access to maternal health. Additionally, qualitative data could be collected through interviews and group discussions to gather feedback and experiences from implementers and beneficiaries. This information could provide insights into the effectiveness of the recommendations and any challenges faced during implementation.

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