Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation

Abstract

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes. Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first ANC visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers. Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

“…Two (15.4%) studies each reported evidence from Burkina Faso and Tanzania, and one (7.7%) each reported from Niger, Sierra Leone, and Nigeria. Eight out of the 13 included studies were conducted in health facility-based settings [4,5,17,[50][51][52][53][54], two in a household-based based setting [11,55], two in community-based settings [56,57], and one was a national survey [58]. The majority (38%) of the included articles were cross-sectional studies [5,17,51,54,56], whilst the minority (8%) was quasi-experimental study design [52] (Fig.…”

“…2). Twelve of the included articles reported evidence on clients' perspective of the quality of maternal healthcare based on free maternal healthcare financing policies [4,5,11,17,[50][51][52][53][54][55][56]58] and one study based on partially free maternal healthcare financing policy [57].…”

“…Of the 13 included studies, 12 underwent methodological quality assessment using the 2018 MMAT [4,5,11,17,[50][51][52][53][55][56][57][58]. All the studies scored between 57.4 and 100%.…”

“…Of the 13 included studies, only five (38.5%) reported evidence of high quality maternal healthcare based on pregnant women's perspective [5,11,[52][53][54]. However, in 8 of the studies, pregnant women were not satisfied with the quality of maternal healthcare rendered under the free maternal care policy [4,17,50,51,[55][56][57][58]. Table 2 presents a summary of the study findings from all the 13 included studies.…”

“…Despite the commendations of the quality of maternal healthcare delivery by pregnant women in some of the included studies, the majority of the included studies revealed low or poor quality of care under the free maternal healthcare policy. In eight of the studies included in this review, pregnant women complained that the quality of services rendered to them under the free maternal healthcare was of low quality owing to several reasons [4,17,50,51,[55][56][57][58]. Amo-Adjei et al, and Belaid and Ridde in their respective studies in Ghana and Burkina Faso revealed that out of pocket (OOP) still existed despite the implementation of free maternal healthcare [56,57].…”