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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.
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