Experiences of care in the context of payment for performance (P4P) in Tanzania

Globalization and Health, Volume 15, No. 1, Year 2019

Interpretation

Background: Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. Methods: A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. Results: Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. Conclusion: Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes. The study was carried out in Rufiji, one of the seven districts in the Pwani region. Rufiji is a rural district and according to the 2012 national census, the district had a population of 217,274 [33]. Administratively, Rufiji is divided into 26 wards [33]. The main economic activity of the district is agriculture and 78% of the inhabitants actively participate in this sector. The main cash crops in the district are cashew nuts, coconut and simsim [34]. The district has a total number of 64 health facilities, including two hospitals, five health centres, and 57 dispensaries [34]. Like many rural districts in Tanzania, Rufiji district faces significant shortages of staff and of the 583 positions in the district health sector, only 301 are filled, a total shortage of approximately 49% [34]. Shortages of qualified staff is more pronounced at low level health facilities, i.e. dispensaries and health centres [35] and among all cadres except the medical attendant category which is overrepresented. Rufiji has a delta zone and during rainy season access to health facilities in the delta is difficult and these health facilities periodically face huge problems in procuring medical supplies and in maintaining regular communication with the district health offices located at the district centre Utete. A qualitative study approach was adopted using focus group discussions (FGDs) and in-depth interviews (IDIs). Data was collected by the first author with the help of a research assistant for a total of six months period, between January 2013–June 2016). Data was collected at 11 health facilities, including two hospitals, two health centres and seven dispensaries. Of these 11 health facilities, four were church-run and seven were public. As the study aimed to elicit the experiences and perceptions of health service users on access and quality of care, it was considered important to conduct FGDs with community members. Under this category of participants, we had discussions with mothers and health facility governing committee (HFGC) members. A total of nine FGDs with 44 participants were conducted, seven with mothers and two with HFGC members, for an overview, see Table Table1.1. All focus groups had an average of five participants, a number encouraged in the literature to increase the range of participation of each participant [36]. FDGs with HFGC members had least participants as these committees have up to five members in total. Mothers were targeted primarily for their in-depth experiences with maternal and child health services. In order to maximize the relevance and quality of our data from this group, we used two criteria to recruit them. Firstly, we targeted women who had at least two children with the older one being at least 5 years old. Secondly, we recruited women who had been residing in the same area (catchment area of a particular health facility) for at least 5 years. The participants were recruited with the help of health workers at health facilities. In practice, we ended up including some informants who could not meet one of the criteria; however the majority of our participants were able to meet the criteria. Overview of FGDs with health service users The second group of FGD participants was the health facility governing committee members. These committees represent community interests at health facilities. The committees were established in Tanzania in 1999, alongside Community Health Fund (CHF). When P4P pilot was introduced, the committees’ duties were expanded to include monitoring if P4P was implemented in ways protecting the interests of the community. The committees consisted of up to 5 members and many of them were very active in community activities and some even hold local political positions. In addition, the members are knowledgeable about the health status profile of their villages and the district. Typically, the person in charge of a health facility acts as the secretary of the committee. To avoid conflicts of interest the secretary was not invited into the FGD with the committee members. In FDGs, a topic guide was used with great flexibility to allow the discussion of emergent issues. The topic guide covered the following issue: experiences with MCH services, quality of health care, access and utilization of health services. To complement the data from the FGDs with community members, we conducted 31 IDIs with health workers of different cadres ranging from medical officers, assistant medical officers, clinical officers, nursing staff, laboratory staff and medical attendants were conducted. Table Table22 provides an overview of study informants. Overview of IDIs All FGDs and interviews except two interviews with Medical Officers were conducted in Swahili. The first author speaks colloquial Swahili, while the research assistant is a Tanzanian citizen with experience in qualitative health services research. All interviews and FGDs were recorded, transcribed in Swahili and then translated into English. In addition, rapid note taking was used. Translations were error checked. Qualitative content analysis was used as the mode of analysis [37], Table Table3,3, gives an overview of the analysis process. The transcripts were subjected to a thorough review before the coding exercise began. Meaning units at manifest level were identified and coded and from these sub-themes and themes were identified. OpenCode 3.6 software [38] was used for data management. Overview of P4P indicators of the Pwani Pilot, Tanzania % of facilities included in the HMIS monthly reports exported through District Health Information System (DHIS) to RHMT in timely manner (by 14th of the following month) % of facilities receiving a copy of a Quarterly District Health Profile report, based on DHIS Overall performance along Examples of moving from meaning units to themes in content analysis of health service users’ FGDs

AI Digest

Study Justification:

– The study explores the experiences of care in the context of Payment for Performance (P4P) in Tanzania.
– It aims to provide insights into the impact, cost-effectiveness, and process evaluations of P4P in the health sector.
– The study argues that understanding the experiences of care in the context of P4P is important for policy agenda setting.

Study Highlights:

– Positive experiences with P4P were reported by study informants, highlighting its potential in improving the availability, accessibility, acceptability, and quality of care (AAAQ).
– However, persistent barriers in the health system of Tanzania contribute to negative experiences of care in the context of P4P.
– The study suggests that while P4P can improve specific services, these improvements cannot be generalized at the health facility level.
– Factors beyond the control of health workers, even in the context of P4P, act as barriers to improving health services.

Study Recommendations:

– Exercise caution when implementing P4P initiatives, despite seemingly positive targeted outcomes.
– Address the persistent barriers in the health system of Tanzania that contribute to negative experiences of care.
– Consider the limitations of P4P in generalizing improvements at the health facility level.
– Explore additional strategies to improve health services beyond the scope of P4P.

Key Role Players:

– Government of Tanzania
– Ministry of Health
– Health workers
– Service users
– Community health governing committee members
– Research assistants

Cost Items for Planning Recommendations:

– Training and capacity building for health workers
– Infrastructure improvements in health facilities
– Procurement of medical supplies
– Communication systems for health facilities in remote areas
– Research and data collection expenses
– Translation and transcription services
– Data analysis software
– Dissemination of study findings
Please note that the cost items provided are examples and may not reflect the actual cost or budget items for implementing the study recommendations.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study design, which provides valuable insights into the experiences of care in the context of Payment for Performance (P4P) in Tanzania. The study includes interviews with health workers and focus group discussions with health service users and health governing committee members. The findings suggest positive experiences with P4P and its potential in improving the availability, accessibility, acceptability, and quality of care. However, the study also highlights persistent barriers in achieving these improvements and the targeted nature of P4P on specific services, which limits its generalizability at the health facility level. To improve the strength of the evidence, future research could consider incorporating quantitative data to complement the qualitative findings and provide a more comprehensive understanding of the impact of P4P on health outcomes. Additionally, expanding the study to include a larger sample size and multiple districts could enhance the generalizability of the findings.

Abstract

The study was carried out in Rufiji, one of the seven districts in the Pwani region. Rufiji is a rural district and according to the 2012 national census, the district had a population of 217,274 [33]. Administratively, Rufiji is divided into 26 wards [33]. The main economic activity of the district is agriculture and 78% of the inhabitants actively participate in this sector. The main cash crops in the district are cashew nuts, coconut and simsim [34]. The district has a total number of 64 health facilities, including two hospitals, five health centres, and 57 dispensaries [34]. Like many rural districts in Tanzania, Rufiji district faces significant shortages of staff and of the 583 positions in the district health sector, only 301 are filled, a total shortage of approximately 49% [34]. Shortages of qualified staff is more pronounced at low level health facilities, i.e. dispensaries and health centres [35] and among all cadres except the medical attendant category which is overrepresented. Rufiji has a delta zone and during rainy season access to health facilities in the delta is difficult and these health facilities periodically face huge problems in procuring medical supplies and in maintaining regular communication with the district health offices located at the district centre Utete. A qualitative study approach was adopted using focus group discussions (FGDs) and in-depth interviews (IDIs). Data was collected by the first author with the help of a research assistant for a total of six months period, between January 2013–June 2016). Data was collected at 11 health facilities, including two hospitals, two health centres and seven dispensaries. Of these 11 health facilities, four were church-run and seven were public. As the study aimed to elicit the experiences and perceptions of health service users on access and quality of care, it was considered important to conduct FGDs with community members. Under this category of participants, we had discussions with mothers and health facility governing committee (HFGC) members. A total of nine FGDs with 44 participants were conducted, seven with mothers and two with HFGC members, for an overview, see Table Table1.1. All focus groups had an average of five participants, a number encouraged in the literature to increase the range of participation of each participant [36]. FDGs with HFGC members had least participants as these committees have up to five members in total. Mothers were targeted primarily for their in-depth experiences with maternal and child health services. In order to maximize the relevance and quality of our data from this group, we used two criteria to recruit them. Firstly, we targeted women who had at least two children with the older one being at least 5 years old. Secondly, we recruited women who had been residing in the same area (catchment area of a particular health facility) for at least 5 years. The participants were recruited with the help of health workers at health facilities. In practice, we ended up including some informants who could not meet one of the criteria; however the majority of our participants were able to meet the criteria. Overview of FGDs with health service users The second group of FGD participants was the health facility governing committee members. These committees represent community interests at health facilities. The committees were established in Tanzania in 1999, alongside Community Health Fund (CHF). When P4P pilot was introduced, the committees’ duties were expanded to include monitoring if P4P was implemented in ways protecting the interests of the community. The committees consisted of up to 5 members and many of them were very active in community activities and some even hold local political positions. In addition, the members are knowledgeable about the health status profile of their villages and the district. Typically, the person in charge of a health facility acts as the secretary of the committee. To avoid conflicts of interest the secretary was not invited into the FGD with the committee members. In FDGs, a topic guide was used with great flexibility to allow the discussion of emergent issues. The topic guide covered the following issue: experiences with MCH services, quality of health care, access and utilization of health services. To complement the data from the FGDs with community members, we conducted 31 IDIs with health workers of different cadres ranging from medical officers, assistant medical officers, clinical officers, nursing staff, laboratory staff and medical attendants were conducted. Table Table22 provides an overview of study informants. Overview of IDIs All FGDs and interviews except two interviews with Medical Officers were conducted in Swahili. The first author speaks colloquial Swahili, while the research assistant is a Tanzanian citizen with experience in qualitative health services research. All interviews and FGDs were recorded, transcribed in Swahili and then translated into English. In addition, rapid note taking was used. Translations were error checked. Qualitative content analysis was used as the mode of analysis [37], Table Table3,3, gives an overview of the analysis process. The transcripts were subjected to a thorough review before the coding exercise began. Meaning units at manifest level were identified and coded and from these sub-themes and themes were identified. OpenCode 3.6 software [38] was used for data management. Overview of P4P indicators of the Pwani Pilot, Tanzania % of facilities included in the HMIS monthly reports exported through District Health Information System (DHIS) to RHMT in timely manner (by 14th of the following month) % of facilities receiving a copy of a Quarterly District Health Profile report, based on DHIS Overall performance along Examples of moving from meaning units to themes in content analysis of health service users’ FGDs

Materials

N/A

Innovations

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

1. Mobile health clinics: Implementing mobile health clinics that can travel to rural areas, such as Rufiji district, to provide maternal health services. This would help overcome the challenge of limited access to health facilities in remote areas.

2. Telemedicine: Introducing telemedicine services to allow pregnant women in rural areas to consult with healthcare professionals remotely. This would improve access to medical advice and reduce the need for travel to health facilities.

3. Community health workers: Expanding the role of community health workers in providing maternal health services, including prenatal care and education, in rural areas. This would increase access to care for pregnant women who may have difficulty reaching health facilities.

4. Improving transportation infrastructure: Investing in improving transportation infrastructure, such as roads and bridges, in rural areas to facilitate easier access to health facilities during the rainy season.

5. Strengthening health facility staffing: Addressing the shortage of qualified staff in health facilities, particularly at the lower levels, by recruiting and training more healthcare professionals. This would help ensure that there are enough skilled personnel to provide maternal health services.

6. Enhancing supply chain management: Implementing effective supply chain management systems to ensure that health facilities in rural areas have a consistent and reliable supply of essential medical equipment and supplies.

7. Community engagement and education: Conducting community engagement and education programs to raise awareness about the importance of maternal health and encourage women to seek care during pregnancy. This would help overcome cultural barriers and increase utilization of maternal health services.

These innovations have the potential to improve access to maternal health services in rural areas, such as Rufiji district, and contribute to the overall goal of improving maternal health outcomes in Tanzania.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the study is to address the persistent barriers that exist in the health system of Tanzania. These barriers contribute to negative experiences of care in the context of Payment for Performance (P4P).

To improve access to maternal health, the following actions can be taken:

1. Strengthen the health system: Address the shortages of staff in health facilities, especially at the lower levels such as dispensaries and health centers. This can be done by recruiting and training more qualified staff to ensure adequate coverage and quality of care.

2. Improve infrastructure and logistics: Address the challenges faced by health facilities in the delta zone during the rainy season, such as difficulties in accessing health facilities and procuring medical supplies. This can be done by improving transportation and communication systems to ensure timely access to health services and supplies.

3. Enhance community engagement: Involve community members, especially mothers and health facility governing committee members, in decision-making processes and monitoring of maternal health services. This can be done by strengthening community health committees and providing them with the necessary resources and support to actively participate in improving maternal health services.

4. Address systemic barriers: Identify and address systemic barriers that hinder access to maternal health services, such as financial constraints, cultural beliefs, and gender inequalities. This can be done through targeted interventions, awareness campaigns, and policy changes to ensure equitable access to maternal health services for all women.

By implementing these recommendations, it is possible to improve access to maternal health and achieve better health outcomes for women in Tanzania.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Strengthening Health Facilities: Address the shortages of staff and improve the infrastructure and resources of health facilities in rural areas like Rufiji district. This could involve recruiting and training more healthcare professionals, ensuring a consistent supply of medical equipment and supplies, and improving communication and transportation systems.

2. Community Engagement: Increase community involvement in maternal health by establishing and empowering health governing committees. These committees can play a crucial role in monitoring the implementation of maternal health programs and advocating for the needs of the community.

3. Mobile Health Technologies: Utilize mobile health technologies, such as mobile apps or SMS messaging, to provide information and reminders to pregnant women and new mothers. This can help improve access to important healthcare information and promote timely and appropriate care-seeking behaviors.

4. Financial Incentives: Explore the use of financial incentives, similar to the Payment for Performance (P4P) program, to motivate healthcare providers to prioritize maternal health services. This could involve rewarding facilities and providers for meeting certain targets related to maternal health outcomes and quality of care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the Key Indicators: Identify the key indicators that will be used to measure the impact of the recommendations. These could include indicators such as the number of skilled healthcare providers per facility, the availability of essential medical supplies, the percentage of pregnant women receiving antenatal care, and the percentage of births attended by skilled birth attendants.

2. Collect Baseline Data: Gather baseline data on the selected indicators before implementing the recommendations. This could involve conducting surveys, interviews, and data analysis to assess the current state of maternal health access in the target area.

3. Implement the Recommendations: Implement the recommended interventions, such as strengthening health facilities, engaging the community, utilizing mobile health technologies, and providing financial incentives. Monitor the implementation process to ensure adherence to the planned interventions.

4. Monitor and Evaluate: Continuously monitor and evaluate the impact of the recommendations on the selected indicators. This could involve collecting data at regular intervals, conducting surveys or interviews with healthcare providers and service users, and analyzing the data to assess any changes in the indicators.

5. Analyze and Interpret the Data: Analyze the collected data to determine the impact of the recommendations on improving access to maternal health. This could involve comparing the baseline data with the data collected after implementing the recommendations and identifying any significant changes or improvements.

6. Adjust and Refine: Based on the findings from the data analysis, make any necessary adjustments or refinements to the recommendations. This could involve scaling up successful interventions, addressing any challenges or barriers identified during the evaluation process, and continuously improving the strategies for improving access to maternal health.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to effectively address the challenges and improve maternal health outcomes.

Author

Dima Health

Statistics:

Citations: 4

Identifiers:

DOI: 10.1186/s12992-019-0503-9

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Tanzania

Study Design:

Cross Sectional Study, Phenomenological Study

Study Approach:

Qualitative

Participants Gender:

Female