Background
Aims and objectives
Methods
Overview
Objective 1. Describe the situation in 21 regions of mainland Tanzania by using tracer indicators related to care at birth for each of the health system building blocks
Contextual factors | Inputs | Outputs | Outcomes | |||||||
---|---|---|---|---|---|---|---|---|---|---|
Tracer indicator | Source | Building block | Tracer Indicator | Source | Building block | Tracer Indicator | Source | Building block | Tracer Indicator | Source |
Total Population (2012) | 2012 census [26] | Governance and leadership | Qualitative analysis - no standardised quantitative data for assessment | Health Service Quality | % women informed of danger signs at ANC | 2010 DHS Report [10] | Coverage Along the Continuum of Care | Proportion of births by rural women by Caesarean section | Original analysis using 2010 DHS [10] | |
GDP per capita | Original analysis using National Accounts 2000-2010 [27] | Health System Financing | Per capita recurrent health expenditure | PMO-RALG Local Government Financial Report (FY 2012/13) [29] | Health Service Utilisation | No data available at regional level | Proportion of births by rural women in a health facility | Original analysis using 2010 DHS [10] | ||
Maternal education | Original analysis using 2010 DHS [10] | Per capital total health expenditure | PMO-RALG Local Government Financial Report (FY 2012/13) [29] | Health Service Readiness | % facilities with improved water source | Tanzania Service Provision Assessment Survey 2014–15 [38] | Equity | Cross-cutting thematic analysis - regional equity | ||
Proportion of births by rural women | Original analysis using worldpop data [28] | Out of Pocket health expenditure | Household Budget Survey 2007 [30] | |||||||
Number of births | Original analysis using worldpop data [28] | Community Health Fund coverage | Fact Sheet Inside NHIF 2001/02 to 30th June 2013 NHIF [33] | |||||||
Rural Birth Density | Original analysis using worldpop data [28] | Official Development Assistance to MNH | Partners Mapping and Resource Tracking 2013/14 with personal communication [31] | |||||||
Total Fertility Rate | Original analysis using worldpop data [28] | Health Workforce | Skilled health workforce density | |||||||
Infrastructure and Commodities | Health facility density - health centres & hospitals | Service Provision Assessment Survey 2014 data provided by personal communication [36] | ||||||||
Availability of essential drugs | National RMNCH scorecard from HMIS data (quarter 4 of 2014) | |||||||||
Health Information Systems | No data accessible | |||||||||
Legislative framework | Not applicable at regional level |
Health financing input
Health workforce input
Health facilities input
Commodities input
Quality of care and health service readiness output
Coverage of care at birth outcome
Objective 2. Undertake a correlation analysis to examine subnational level associations between health systems inputs, outputs and outcomes
Objective 3. Use GIS mapping techniques to visualise subnational variation for care at birth outcomes with barometers of health system readiness
Objective 4. Explore qualitatively the governance and management of health financial flows
Results
Objective 1. Describe the situation in 21 regions of mainland Tanzania by using tracer indicators related to care at birth for each of the health system building blocks
Health financing input
Health workforce, facilities, and commodities inputs
Quality of care and health service readiness output
Coverage of care at birth outcome
Objective 2. Undertake a correlation analysis to examine subnational level associations between health systems inputs, outputs and outcomes
Health financing input
Health workforce input
Health facilities input
Commodities input
Quality of care and health service readiness output
Coverage of care at birth outcome
Objective 3. Use GIS mapping techniques to visualise subnational variation for care at birth outcomes with barometers of health system readiness
Health financing input
Health workforce input
Health facilities input
Commodities input
Health system implementation readiness
Objective 4. Explore qualitatively the governance and management of health financial flows
“Malaria, HIV and maternal and newborn health are the top priorities, we will not get the budget approved if those three are not mentioned…” (district budget planner)
“We [are] 100 % basket fund. If there’s no basket fund we cannot go to visit the facilities, for example. […] We can’t buy most of the supplies that are urgently needed and that currently may be frequently missing from medical stock.” (CHMT member)
Discussion
Widespread subnational gaps in health system readiness for care at birth
Explaining variation in care at birth services for rural women
Limitations and future research
Conclusions
National and global implications
Key messages
|
1. Novel analysis of subnational variation in health systems inputs: This is the first study to use GIS mapping techniques to visualise subnational health system readiness for care at birth across mainland Tanzania, and particularly to better understand this variation by examining finance and other inputs. |
2. Widespread subnational gaps in health system readiness for care at birth: No region meets the benchmarks for all four health systems building blocks including for health finance, health workforce, health facilities, and commodities. |
3. Explaining variation in care at birth services for rural women: Significant correlations were found between proportion of rural women delivering in a health facility, and by Caesarean section with health system readiness indicators including human resources density, health facility density, availability of essential commodities, and quality of care. However, some outlier Tanzanian regions, e.g., Kagera, demonstrate improved delivery of care at birth services for rural women despite receiving suboptimal resources; which has implications for similar settings, and needs further investigation to understand why and how this is occurring. |
4. Research agenda: Future research to improve care at birth services for rural women should take into account data on governance and leadership, demand and community engagement, and efficiency in use of resources. Further investigation is needed into understanding positive outlier regions within Tanzania demonstrating improved service provision despite facing resourcing challenges. Considerable research is also needed to improve health systems input data, particularly on health workforce and standard benchmarks. |