Abstract
BackgroundMany low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures.MethodsWe compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system.FindingsThe distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the “basic needs” poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the “basic needs” poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard.ConclusionIn choosing poverty identification strategies for programmes seeking to enhance health equity it’s necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities.
Highlights
Many low income countries have policies to exempt the poor from user charges in public facilities
In choosing poverty identification strategies for programmes seeking to enhance health equity it’s necessary to balance between community acceptability, local relevance and the need for such a strategy
Almost 80 % of the surveyed household heads had completed primary education, most (85.7 %) of the households were subsistence farmers, and only 2.9 % were enrolled in the Community Health Fund (CHF) insurance scheme
Summary
Many low income countries have policies to exempt the poor from user charges in public facilities. The most common approaches to identify the poor for user fee exemptions include: proxy means testing, whereby a limited number of household or individual characteristics are used to judge poverty [10], the community or participatory wealth ranking method, whereby community members or leaders rank neighbouring households [11], and geographic targeting, whereby all residents in a given geographic area (e.g., village, district) are identified as poor (this is sometimes combined with community and proxy means testing) [12]. A lack of reliable methods to identify poor people in the community has affected implementation of exemption policies in low and middle income countries [15]
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