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User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania

Archived Abstract of Former PSC Researcher

Kruk, M.E., G. Mbaruku, P.C. Rockers, and Sandro Galea. 2008. "User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania." Tropical Medicine and International Health, 13(12): 1442-1451.

To identify the main drivers of costs of facility delivery and the financial consequences for households among rural women in Tanzania, a country with a policy of delivery fee exemptions. We selected a representative sample of households in a rural district in western Tanzania. Women who given birth within 5 years were asked about payments for doctor's/nurse's fees, drugs, non-medical supplies, medical tests, maternity waiting home, transport and other expenses. Wealth was assessed using a household asset index. We estimated the proportion of women who cut down on spending or borrowed money/sold household items to pay for delivery in each wealth group. In all, 73.3% of women with facility delivery reported having made out-of-pocket payments for delivery-related costs. The average cost was 6272 Tanzanian shillings (TZS), [95% Confidence Interval (CI): 4916, 7628] or 5.0 United States dollars. Transport costs (53.6%) and provider fees (26.6%) were the largest cost components in government facilities. Deliveries in mission facilities were twice as expensive as those in government facilities. Nearly half (48.3%) of women reported cutting down on spending or borrowing money/selling household assets to pay for delivery, with the poor reporting this most frequently. Out-of-pocket payments for facility delivery were substantial and were driven by high transport costs, unofficial provider payments, and preference for mission facilities, which levy user charges. Novel approaches to financing maternal health services, such as subsidies for transport and care from private providers, are required to reduce the cost barriers to attended delivery.Identifier les principaux facteurs des couts des services d'accouchement et les consequences financieres sur les menages parmi les femmes rurales en Tanzanie, un pays avec une politique d'exemption des frais d'accouchement. Nous avons selectionne un echantillon representatif de menages dans un district rural dans l'ouest de la Tanzanie. Les femmes qui ont accouche dans les cinq ans ont ete interrogees au sujet des paiements des honoraires de medecin/infirmiere, des medicaments, des fournitures non medicales, des examens medicaux, de la salle d'attente de maternite, du transport et autres frais. La richesse a ete evaluee a l'aide d'un indice des biens des menages. Nous avons estime la proportion de femmes qui ont reduit leurs depenses ou emprunte de l'argent ou vendu des biens du menage afin de payer pour l'accouchement dans chaque groupe de richesse. 73,3% des femmes avec un accouchement dans les services ont declare avoir effectue des paiements pour des couts lies a l'accouchement. Le cout moyen etait de 6272 shillings tanzaniens (TZS), (intervalle de confiance (IC)95%: 4916 a 7628) ou 5,0 dollars des Etats-Unis (USD). Les frais de transport (53,6%) et les frais pour les honoraires (26,6%) etaient les plus importants elements des couts dans les services federaux. Les accouchements dans les services de la Mission etaient deux fois plus chers que ceux dans les services federaux. Pres de la moitie (48,3%) des femmes ont declare reduire leurs depenses ou emprunter de l'argent ou vendu des biens du menage afin de payer pour l'accouchement, les pauvres rapportant cela plus souvent. Les paiements de poche pour les services d'accouchement etaient importants et etaient menes par des couts eleves du transport, des paiements d'honoraires non officiels et a la preference pour les services de la Mission qui percoivent des droits d'usage. De nouvelles approches pour le financement des services de sante maternelle, telles que les subsides pour le transport et les soins des fournisseurs prives, sont necessaires pour reduire les barrieres de cout a faire recours aux services d'accouchement.Identificar los principales factores responsables de los costes de servicios obstetricos durante el parto en centros sanitarios y sus consecuencias financieras para los hogares, entrevistando a mujeres de zonas rurales de Tanzania, un pais con una politica de servicios obstetricos gratuitos. Hemos seleccionado una muestra representativa de hogares en un distrito rural del oeste Tanzania. Se le pregunto a las mujeres que habian dado a luz en los ultimos cinco anos sobre los pagos de honorarios a medicos(enfermeras, medicamentos, suministros no medicos, pruebas medicas, hogar de espera, transporte y otros gastos. La riqueza se evaluo utilizando un indice de activos del hogar. Dentro de cada grupo de riqueza, se estimo la proporcion de mujeres que redujeron los gastos o pidieron dinero prestado/vendieron objetos del hogar para pagar el parto. Un 73.3% de las mujeres que dieron a luz en el centro sanitario reportaron haber realizado gastos de bolsillo para cubrir costes relacionados con el alumbramiento. El coste medio fue de 6,272 shillings tanzanos (TZS), (95% Intervalo de confianza (IC): 4,916, 7,628) o 5.0 dolares americanos (USD). Los gastos de transporte (53.6%) y honorarios a proveedores (26.6%) fueron los componentes mas grandes en los centros gubernamentales. Los partos en centros de misioneros fueron dos veces mas caros que aquellos realizados en centros gubernamentales. Casi la mitad (48.3%) de las mujeres reportaron haber reducido otros gastos o haber pedido dinero prestado/vendido activos del hogar para pagar el parto, siendo las mas pobres quienes mas frecuentemente lo reportaron. Los gastos de bolsillo para dar a luz en un centro sanitario eran sustanciales y estaban principalmente relacionados con los altos costes del transporte, pagos no oficiales al proveedor, y preferencia por utilizar los centros misioneros - que tienen honorarios establecidos. Nuevas aproximaciones para la financiacion de los servicios sanitarios maternos, tales como el subsidio para el transporte o la atencion de proveedores privados, son necesarios para reducir las barreras economicas de un parto con atencion sanitaria.

DOI:10.1111/j.1365-3156.2008.02173.x (Full Text)

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