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Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania.

Mikkelsen-Lopez I, Tediosi F, Abdallah G, Njozi M, Amuri B, Khatib R, Manzi F, de Savigny D - BMC Health Serv Res (2013)

Bottom Line: Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76.System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure.Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.

View Article: PubMed Central - HTML - PubMed

Affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland. i.mikkelsen-lopez@unibas.ch.

ABSTRACT

Background: To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania.

Methods: We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility.

Results: Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding.

Conclusion: System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.

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Care seeking and average direct costs during fever episodes, Ulanga District, Tanzania, November 2009 – August 2011. Note that the number of non-compliant cases (i.e. cases subject to non-compliant behaviour of health care workers) in the public sector does not sum to total non-compliant cases due to some individuals experiencing more than one non-compliant behaviour at the health facility during fever treatment.
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Figure 3: Care seeking and average direct costs during fever episodes, Ulanga District, Tanzania, November 2009 – August 2011. Note that the number of non-compliant cases (i.e. cases subject to non-compliant behaviour of health care workers) in the public sector does not sum to total non-compliant cases due to some individuals experiencing more than one non-compliant behaviour at the health facility during fever treatment.

Mentions: A more detailed breakdown of these costs, showing cases which were subjected to non-compliant behaviour of any sort by health care workers can be seen from Figure 3. Non-compliant behaviour was relatively more common in the public sector, with overcharging for medicines being the most common form.


Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania.

Mikkelsen-Lopez I, Tediosi F, Abdallah G, Njozi M, Amuri B, Khatib R, Manzi F, de Savigny D - BMC Health Serv Res (2013)

Care seeking and average direct costs during fever episodes, Ulanga District, Tanzania, November 2009 – August 2011. Note that the number of non-compliant cases (i.e. cases subject to non-compliant behaviour of health care workers) in the public sector does not sum to total non-compliant cases due to some individuals experiencing more than one non-compliant behaviour at the health facility during fever treatment.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3815072&req=5

Figure 3: Care seeking and average direct costs during fever episodes, Ulanga District, Tanzania, November 2009 – August 2011. Note that the number of non-compliant cases (i.e. cases subject to non-compliant behaviour of health care workers) in the public sector does not sum to total non-compliant cases due to some individuals experiencing more than one non-compliant behaviour at the health facility during fever treatment.
Mentions: A more detailed breakdown of these costs, showing cases which were subjected to non-compliant behaviour of any sort by health care workers can be seen from Figure 3. Non-compliant behaviour was relatively more common in the public sector, with overcharging for medicines being the most common form.

Bottom Line: Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76.System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure.Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.

View Article: PubMed Central - HTML - PubMed

Affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland. i.mikkelsen-lopez@unibas.ch.

ABSTRACT

Background: To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania.

Methods: We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility.

Results: Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding.

Conclusion: System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.

Show MeSH
Related in: MedlinePlus