Menu
Menu
Menu
Menu
BACKGROUND: Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services.
This case study used a mixed methods approach. We conducted a quantitative assessment of facility use in a sample of the population in Rungwe district and whether the most disadvantaged women, as indicated by their educational status, had taken advantage of the MCH cards to deliver in a facility. Use of a qualitative method enabled the research team to explore women’s decisions on birth place, birth experience itself, and use of the MCH card. The Rungwe district in Mbeya region was purposively selected for data collection. It was the only district in the region that had implemented individual targeting before adopting geographic targeting, and thus, it offered not only the opportunity to describe women’s and providers’ experiences with the current geographic targeting strategy but also explores providers’ attitudes towards both strategies and the reasons for abandoning individual targeting. Data related to the switch from individual targeting to geographical targeting will be reported in a second paper [19]. Purposive sampling was used to select representative facilities at the district, ward, facility, and community level. The district hospital and both health centres were included, and four dispensaries were selected based on physical accessibility, enrolment rate to the MCH insurance card, and being served by a health centre. Thus, a total of seven health care facilities and their catchment areas were included in the study. No routine data were available from medical or programme records to evaluate the extent to which more disadvantaged women were delivering in facilities compared to their less disadvantaged peers. The health care facilities were visited, and the researchers reviewed the MCH card beneficiary register book for the women who had delivered between January and December 2013. All the beneficiaries were listed on a paper as they appear in the register book at the facility. Thereafter, a systematic random sampling was used, whereby the team leader identified a starting point and subsequent beneficiaries were identified at an interval of five. A total of 30 women from each dispensary, 20 women from each health centre, and 40 women from the hospital were identified for an interview. Their telephone numbers were obtained from the registry, and the research team had to set appointments for a telephone survey with the beneficiaries on the same day or a day after. To assess the factors influencing women’s use of the MCH card and decision-making regarding delivery location, two women, one who had the MCH card and delivered at home and one who had the card and delivered at a facility, were randomly selected from the register at each facility. Interviews were conducted at the women’s homes. The research team also conducted interviews during the facility visit with purposively selected health workers, traditional birth attendants, and village leaders. A total of 31 in-depth interviews (IDIs) were conducted in September 2014. Interview guides contained a range of topics in relation to the decision about place of birth, knowledge about the insurance scheme, and recommendations about maternal and child health services. Interview guides were created in English and subsequently translated into Kiswahili by the bilingual research team and research assistants, who also conducted the interviews. The research team conducted interviews in pairs: one facilitated the interview while the other took notes. All interviews were also digitally recorded, and the audio files were transcribed and translated by a research assistant. In addition, the researchers cross-checked the audio files and transcripts for data quality assurance. To assess equity, three categories of education levels were used: no education (did not attend school or dropped out before completing basic primary school), primary school (basic primary school education up to standard seven), and secondary school (secondary education and above). A comparison of the beneficiaries’ education was compared with the educational distribution of women who had delivered a child in the previous 5 years from the Tanzania Demographic Household Survey (TDHS) of 2010 and a household survey conducted in one of the districts in Mbeya by Ifakara Health Institute in February 2014. Microsoft Excel was used for the analysis. 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 to agree on the final themes. The team worked together and coded a few transcripts together to ensure consistency and then each worked independently on the remaining transcripts. The team then combined and discussed the coded transcripts and identified themes and appropriate quotations for the manuscript. Data were analysed using NVivo 10 software. Ethical clearance for this study was obtained from the Ifakara Health Institute Institutional Review Board (IRB) IHI/IRB/No 12-2014. Written consent was sought from the study participants after the team leader had explained the objectives of the study. Participants were informed that their participation was voluntary and at any time, they had the right to withdraw without any penalty. The field team assured participants about confidentiality of all information throughout the study. Interviews were conducted in the local language (Kiswahili) and tape recorded with the permission of the study participants.
N/A
