Abstract
BackgroundThe use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012.MethodsA controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective.DiscussionThis evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature.
Highlights
The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries
Stagnating maternal and neonatal indicators in many countries of Sub-Saharan Africa are a major concern for national governments and development partners striving to achieve the Millennium Development Goals (MDGs) [1, 2]
All government health facilities are accredited irrespective of the quality of care they provide, and many private for profit and faith-based (FBO) facilities that meet pre-defined quality standards1 are accredited. Unemployed individuals or those working outside the formal sector are not eligible for National Health Insurance Fund (NHIF) coverage, but can join a community based health insurance scheme which provides access to primary health care with limited referral care for its members, the Community Health Fund (CHF), which is managed by the NHIF; enrolment levels remain low
Summary
The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. Stagnating maternal and neonatal indicators in many countries of Sub-Saharan Africa are a major concern for national governments and development partners striving to achieve the Millennium Development Goals (MDGs) [1, 2]. These indicators are poorest among low-income populations. There have been many studies examining the determinants of skilled attendance at delivery; the emphasis has been on individual and household characteristics more than on supply side factors that may affect demand [3], such as cost and quality of care. The financial incentives of providers to maximize facility revenue are at odds with a policy which would reduce that revenue quite substantially by providing free services to certain groups
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