Payments and Quality of Ante-Natal Care in Two Rural Districts of Tanzania

This paper surveys women’s experiences with payments for ante-natal care (ANC) and associated issues of quality in two rural districts of Tanzania. We draw on quantitative and qualitative data from interviews in facilities and in households in the two districts to explore these issues, and discuss some policy implications. The paper provides evidence of payments for ANC in the two rural districts. Striking differences in payments between the two districts were observed, apparently reflecting variation in charging practices in different parts of the districts. In the areas surveyed in one district, women were paying little, in both faith-based organisations (FBOs) and in the public sector. In the other district, charges were much higher in facilities that women had attended, including a district hospital and a public dispensary that seemed to have gone into business on its own account. We explore to what extent these higher charges were associated with better-quality care: The women in the higher-charging district had in general received somewhat higher levels of service than the women interviewed in the lower-charging district, with the notable exception of a low-charging FBO-owned hospital that was succeeding in combining low and predictable charges with good services. In both districts, we found few reports of abuse at the ANC level – this appears to be more a problem at birth. The main quality issues at this level are lack of basic ANC services in some of the public health facilities, and having to pay for ANC even in some of the public facilities where these services are supposed to be provided for free. However, the problem of supply shortages seems to have generated a system of informal charging in some contexts. Sale of assets and borrowing to pay for ANC means impoverishment in order to access a payment-exempted service. We also found that health insurance appears to be creating or supporting a culture of charging for ANC. ANC accessible to all women is a key requirement for improved maternal survival. The findings discussed in this paper suggest the need for a more concerted effort to implement effectively strategies that are already in place, and to come up with other alternative strategies that may result into better outcomes. Such strategies should not be considered in isolation, but should be part of effective strategies to improve all aspects of maternal health. Furthermore, an emerging problem needs to be looked into, and appropriate action taken. Health insurance, which is intended to promote access to health care for the poor, seems in this case to be creating a contrary effect by exacerbating the problem of payments for services that should be exempted from payment.\u