THE DELIVERY OF HEALTH SERVICES IN KINONDONI

MUNICIPAL: CIVIL SERVANTS’ PERCEPTIONS

By

Felician Zephrine Mufumu

Dissertation Submitted to Mzumbe University – Dar es Salaam Campus College

for the Requirements of the award of a Master Degree in Public Administration

of Mzumbe University

2013

i

CERTIFICATION

We, the undersigned, certify that we have read and hereby recommend for acceptance

by the Mzumbe University, a dissertation entitled The Delivery of Health Services in

Kinondoni Municipal: Civil Servants’ Perceptions, in partial fulfillment of the

requirements of award of the Degree of Master of Public Administration (MPA) of

Mzumbe University.

____________________________

Major Supervisor

____________________________

Internal Examiner

Accepted for the Board of

_________________________________________________________________

DEAN/DIRECTOR, FACULTY/DIRECTORATE, SCHOOL BOARD

ii

DECLARATION AND COPYRIGHT

I Felician Zephrine Mufumu, do hereby declare to the Faculty of Public

Administration of Mzumbe University – Dar es Salaam Campus College, Tanzania,

that this research is my own work and has not been submitted for Master Degree Award

at any other university or institution of higher learning.

Signature____________________________

Date ________________________________

©

All rights reserved. No part of this research may be reproduced in any form or by any

means, electronic or mechanical, including photocopying, recording or any

information storage or retrieval system without prior permission from the author or

Mzumbe University.

iii

ACKNOWLEGMENT

I would like to thank the Municipal Medical Officer of Kinondoni municipal for

granting me permission to conduct my study in the municipal health facilities. Special

thanks should also go to Medical Officers in-charge and staff of Lugalo hospital,

Mwananyamala hospital, Sinza hospital, Magomeni health centre and Tandale

dispensary for their great contributions.

iv

DEDICATION

I dedicate this work to my lovely wife Captain Jamila Nyanza and my daughter Stella

who really missed my love during the busy times of my studies.

I also dedicate this work to my beloved parents the late DR. Mufumu and Mrs.

Mufumu for their good parental care, for giving me good foundation in my education

also for giving me an opportunity to make a difference in their lives.

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ABBREVIATIONS

ADDO - Accredited Drug Distribution Outlet

AIDS - Acquired Immuno – Deficiency Syndrome

CCM - Chama Cha Mapinduzi

CHF - Community Health Fund

FBO - Faith Based Organization

HIV - Human Immuno Deficiency Virus

HSR - Health Sector Reform

ILO - International Labour Organization

IMF - International Monetary Fund

MCHA - Maternal and Child Health Aides

MDG - Millennium Development Goal

MOH - Ministry of Health

MOHSW - Ministry of Health and Social Welfare

NGO - Non Governmental Organization

NHI - National Health Insurance

NHIC - National Health Insurance Corporation

NHIF - National Health Insurance Fund

NIC - National Insurance Corporation

NIMR - National Institute of Medical Research

PMO-LAG - Prime Minister Office, Regional Administration and Local

Government

RHMT - Regional Health Management Team

SAP - Structural Adjustment Program

SSA - Sub-Saharan Africa

TDV - Tanzania Development Vision

WB - World Bank

WHO - World Health Organization

vi

ABSTRACT

The study was set out to assess health services delivery as perceived by civil servants

in Kinondoni municipal health facilities using Lugalo, Mwananyamala, sinza,

Magomeni and Tandale with a particular interest to clients who are member of NHIF.

The specific objectives were to assess the perception of civil servants on health care

services provided in Kinondoni municipal health facilities, to assess the contribution

of health insurance towards the improvement of health care services and to elicit civil

servants opinions on how to improve health care services provided in Kinondoni

municipal health facilities.

The findings of the study revealed that respondents were satisfied with health care

services they had received in Kinondoni municipal health facilities, particularly on

consultation time, information sharing and client – provider interaction, the cleanliness

of the facilities surroundings and physical state of the facilities buildings.

Also the findings of the study revealed that respondents perceived shortage of

medicines, medical supplies and equipments as a problem in all the municipal health

facilities under the study. The findings also revealed lack of privacy, but generally it

was concluded that the health care services delivered in Kinondoni municipal health

facilities was satisfactory.

In order to improve the delivery of health care services in Kinondoni municipal health

facilities, respondents suggested that, availability of medicines, medical supplies and

equipments should be improved. Also, health care providers should be well trained

and adequate.

TABLE OF CONTENTS

vii

Pages

CERTIFICATION ...................................................................................................... i DECLARATION ........................................................................................................ ii COPYRIGHT ................................................................ Error! Bookmark not defined.

ACKNOWLEGMENT ............................................................................................. iii DEDICATION ........................................................................................................... iv ABBREVIATIONS .................................................................................................... v ABSTRACT ............................................................................................................... vi

TABLE OF CONTENTS .......................................................................................... vi LIST OF TABLES .................................................................................................... ix

LIST OF FIGURES ................................................................................................ viii

LIST OF APPENDICES .......................................................................................... ix

CHAPTER ONE ........................................................................................................ 1 INTRODUCTION ...................................................................................................... 1

1.1 Background to the Problem ....................................................................... 3

1.2 Statement of the Problem .......................................................................... 7 1.3 Research Questions ................................................................................... 9

1.4 Objective of the Study ............................................................................... 9 1.4.1 General Objective ...................................................................................... 9

1.5 Specific Objectives .................................................................................. 10 1.6 Significance of the Study ........................................................................ 10

1.7 Area and Scope of the Study ................................................................... 10 1.8 Limitations of the Study .......................................................................... 10 1.9 De – limitations ....................................................................................... 11

CHAPTER TWO ..................................................................................................... 11

LITERATURE REVIEW ........................................................................................ 11 2.1 Introduction ............................................................................................. 12 2.2 Theoretical Perspectives .......................................................................... 14

2.2.1 Market Failure ......................................................................................... 14

2.2.2 Government Failure................................................................................. 15

2.3 Quality of Health Care Services .............................................................. 15 2.4 National Health Policy ............................................................................ 21 2.5 Health Delivery System in Tanzania ....................................................... 22

2.6 Health Sector Reforms ............................................................................ 26 2.7 Health for All (Universal Coverage) ....................................................... 29

2.8 Health Expenditure and Financing in Developing Countries.................. 30 2.9 Health Insurance Schemes ...................................................................... 31 2.10 Health Financing in Tanzania ................................................................. 32

2.11 Effects of Costs on Health Seeking Behavior ......................................... 34

CHAPTER THREE ................................................................................................. 34 RESEARCH METHODOLOGY ........................................................................... 34

3.1 Introduction ............................................................................................. 34

viii

3.2 Study Area ............................................................................................... 35 3.3 Study Design ........................................................................................... 35

3.4 Study Population ..................................................................................... 35 3.5 Sample and Sampling Technique ............................................................ 36 3.6 Data Collection Instruments .................................................................... 37 3.6.1 Questionnaire .......................................................................................... 37 3.6.2 Interview.................................................................................................. 37

3.6.3 Observation ............................................................................................. 38 3.7 Data Analysis .......................................................................................... 38

CHAPTER FOUR .................................................................................................... 39 PRESENTATION OF FINDINGS .............................. Error! Bookmark not defined.

4.1 Introduction ............................................................................................. 40

4.2 Respondent Interview .............................................................................. 40

4.3 Facility Checklist..................................................................................... 48

4.3.1 Services Offered ...................................................................................... 48

4.3.2 State of Physical Structures ..................................................................... 49

4.3.3 Environmental Cleanliness ...................................................................... 49

CHAPTER FIVE ...................................................................................................... 50

DISCUSSION OF THE FINDINGS ....................................................................... 50 5.1 Introduction ............................................................................................. 50 5.2 Provider – Client Interaction ................................................................... 51

5.3 Availability of Medicines and Medical Supplies .................................... 52 5.4 Waiting Time........................................................................................... 53

5.5 Physical State of Buildings ..................................................................... 54 5.6 Patients’ Satisfaction or Dissatisfaction with Health Services Delivery . 54 5.7 Market Failure ......................................................................................... 57

5.8 Government Failure................................................................................. 58

CHAPTER SIX ........................................................................................................ 59 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ......................... 59

6.1 Introduction ............................................................................................. 59 6.2 Summary ................................................................................................. 59

6.3 Conclusion ............................................................................................... 60 6.4 Recommendations ................................................................................... 61 6.4.1 Specific Recommendations ..................................................................... 61 6.4.2 General Recommendations ..................................................................... 62 6.4.3 Areas for Further Researches .................................................................. 62

REFERENCES ......................................................................................................... 62

APPENDICES .......................................................................................................... 68

LIST OF TABLES

Pages

ix

Table 1.1: Health Facilities Registered by the Fund Up to March 2012 ............... 7

Table 2.1: Dimensions of Quality Health Service…………………………..….17

Table 2.2: Conceptual Framework for Assessing Health Service Quality……..19

Table 2.3: Countries that have Achieved Universal Coverage in the World 30

Table 2.4: Implementation of Universal Coverage in African countries ............ 30

Table 4.1: Socio-Demographic Characteristics of Respondents Interviewed ..... 40

Table 4.2: Reasons for Choice of Health Facility ............................................... 41

Table 4.3: Mode of Transport Used By Respondents to Attend at the Health

Facilities ............................................................................................. 42

Table 4.4: Respondents’ Perception on Drug Availability at the Health Facility 42

Table 4.5: Respondents’ Perception on Health Care Providers’ Attitude ........... 43

Table 4.6: Respondents’ Opinions on Adequacy of Consultation Time ............. 43

Table 4.7: Respondents Given Adequate Explanations of their Health Problems

............................................................................................................ 44

Table 4.8: Respondents Reported to have Been Counseled ................................ 44

Table 4.9: Respondents Given Instructions on How to Use Prescribed Medicines

............................................................................................................ 45

Table 4.10: Respondents Examined Physically and Privacy Maintained ............. 45

Table 4.11: Respondents’ Perception on Physical State of the Buildings ............. 46

Table 4.12: Respondents’ Perception on Total Time to Get Health Care Services

............................................................................................................ 46

Table 4.13: Respondents’ Satisfaction with the Quality of Health Care Services 46

Table 4.14: Respondents’ Reasons for Satisfaction with Quality of Health Services

............................................................................................................ 47

Table 4.15: Respondents’ Reasons for Dissatisfaction with the Quality of Services

............................................................................................................ 47

Table 4.16: Respondents’ Recommendations on Improving the Health Services 48

Table 4.17: Various Services Provided in Municipal Health Facilities ................ 49

LIST OF FIGURES

Figure 2: 1 Figure 2.1: Health Quality Dimensions Relationship......................... 18

x

Figure 2.2: The Health System in Tanzania ............................................................... 24

Figure 2.3: Ministries, Departments and Agencies Most Involved in Health

Sector and their Responsibilities …………………………………………………..26

LIST OF APPENDICES

Pages

xi

Appendix 1: The Informed Concert ........................................................................ 68

Appendix 2: Client Questionnaire (English Version) ............................................. 70

Appendix 3: Clients Questionnaire (Swahili Version) ............................................ 81

Appendix 4: Facility Check List to Assess Health Services Delivered .................. 91

1

CHAPTER ONE

INTRODUCTION

Since independence in 1961, the Government of Tanzania has consistently focused her

development strategies on combating ignorance, diseases and poverty. The investment

in health services is recognized as a potential tool in fighting diseases and at the same

time improving the quality of lives of the majority of the people.

For more than two decades Tanzania has been one party state. One of the major

directives of the ruling party was that the health services should be available to all

Tanzanians. To implement these directives the government made health provision free

of charge. It further expanded health services delivery units by building dispensaries

and health centers in rural areas where the majority of the population lived. The

government remained the main provider of health services in the country and the sole

source of health financing. Her effort in health services provision were supplemented

to the not for profit NGO’s. Development for the private-for-profit sector was

discouraged (MOH, 2001).

However, the problems of implementation of vertical programs, inappropriate

utilization of manpower, improperly functioning referral system, shortage of staff,

inadequate medical equipments and other medical supplies made the government to

change its role from that of main provider to facilitator of health services and adopt

use fee as an alternative health financing mechanism (MOH, 2000).

User fee (health insurance) is not a new phenomenon in most of the third world

countries. It has been practiced by private health facilities and Non Governmental

Organizations for many years ago (Shaw, 1995).

Health care services were previously provided free of charge in most of developing

countries especially in Africa and other third world countries. The need to provide for,

accessible, equitable, effective and sustainable health services was a political decision

2

made by most of African leaders soon after independence of their countries in early

1960s. However, due to economic crisis which was facing the world in early 1980s the

WB and IMF introduced Structural Adjustment Programs. SAP’s were accompanied

with a number of reforms, HSR was one of them. Health insurance was an important

aspect of HSR. It is a part of wide perspective of financial reforms. Together with other

reforms in the health sector, it is intended to create a sustainable, purposeful and

fundamental change to address significant strategic dimension in health system

(Berman, 1995).

The primary purpose of health insurance is to generate revenue. In public sectors fees

are usually introduced to supplement public funds when those sectors fails to keep up

with the cost of providing services and expanding services to meet increasing demand.

Although the primary purpose is to generate revenue but the total amount of revenue

generated is unlikely to be sufficient to meet the growing need and demand for high

quality health care services (Newbrander and Sacca, 1996).

In Tanzania, the concept of NHI for employees in the formal sector evolved from a

number of concerns that have risen regarding the financial sustainability of the health

sector. The concerns were based on observed decline in the amount of resources

flowing into the sector, of which has resulted in decrease in the availability and quality

of health services provided. Between 1990 and 1992 the MOH carried out a health

financing study which recommended user fee in the government health facilities and

development of NHI for employees in the formal sector.

The introduction of alternative health financing mechanisms such as user fees,

Community Health Fund and National Health Insurance Fund was viewed as a means

of generating additional revenue for the health sector, improving quality of health

services, as well as promoting equity, accessibility, and efficiency in the use of health

services in Tanzania (MOH, 1997).

3

The government in July 1993 adopted the policy of cost sharing in government health

facilities. This policy was preceded by pilot studies which indicated that the

communities were willing to pay by anticipating that drugs will be available with well

maintained health facility infrastructures and improved doctor – patient relationship

and availability of other medical supplies (Mujinja and Mabara, 1992). That decision

was a major departure to the previous policy of providing free health care services at

the point of health delivery.

In Kinondoni municipal, the introduction of health insurance for civil servants started

in October 2001. Before the introduction of health insurance, health services were

provided by cost sharing and in some places were given free of charge. However, the

health care services provided were of poor quality due to lack of medicine and other

medical supplies, inadequate staff and poor health facility infrastructures.

This study aimed at determining how can health services delivered in Kinondoni

municipal health facilities (as perceived by civil servants) were improved.

1.1 Background to the Problem

The delivery of health services in Tanganyika then Tanzania began during the German

colonialism (1888 - 1891) along the coast areas of Tanga, Pangani, Bagamoyo, Dar es

Salaam and Kilwa (Clyde 1962). Further expansion of the services was limited during

this time because much of the country had not been explored. In developing health

services in these areas, the Germans were mainly guided by economic and

administrative factors.

When the British colonialists came in the period between 1916 – 1920 they devoted to

the reconstruction and re-establishment of civil medical services upon which the

country current medical services are based. Since then, there have been minimal

reforms to Tanzania Mainland health services. Save for the Titmus Report (1966), the

Arusha Declaration (1967) which emphasized on health services delivery in rural areas

and the Acts on Decentralization (1972 and 1982) that gave decision making autonomy

to the districts.

4

The primary health care service forms the basement of pyramidal structure of health

care services. It is made up of a number dispensaries, health centers and district

hospitals. Currently, the health facilities for both public and private include 4679

dispensaries, 481 health centers and 219 hospitals distributed throughout the country.

The dispensaries and health centers are planned to service an average population of

10,000 and 50,000 respectively (MOH, 2007).

However, with increasing population and slow pace of construction of primary health

care facilities, the average population served by these facilities is more than the

planned population. The problem as stated earlier is compounded with shortage of

staff, inadequate medical equipments and other supplies. To meet all these challenges,

the government has decided to adopt user fee in its health facilities as an alternative

health financing mechanism (MOH, 1996).

Human beings irrespective of their income, races, nationality or level of social

economic developments, they all need protection against ill-health, related health

shocks and costs of illness. Tanzania realized this and it concurred with the idea:

“Nothing in the history of a social policy that has transformed the life of an ordinary

man than an assurance that in the event of ill-health, he will not turn into destitute”

(Jenks, 1971), thus it established NHI.

Since 1883, when the first Social Health Insurance Scheme in the world (the Bismarck

model) was introduced in Germany, the world witnessed a notable developments and

reforms aimed at achieving the goal of health for all. Globalization, the MDGs and the

need by the International Community to reduce poverty are therefore international

intervention strategies geared towards establishing systems which ensure every citizen

of the community is protected against shocks and causes of ill-health.

Some of the international declarations, Regional initiatives or National policies that

have been adopted or implemented are:

5

(i) ILO (1952) that minimum standards on coverage required to be extended to the

society that includes medical care.

(ii) The Arusha Declaration (1967) that provides for the right of social protection.

(iii) WHO (1978) health for all initiative, the Alma-Ata Declaration.

(iv) The Health Policy (1990) aimed at equitable and accessible health care services

by all.

(v) The Social Security Policy (2003) aimed at social protection and harmonization

mainly of the pension sector.

(vi) WB (2005) Integrating Health Insurance in social protection.

Immediately after independence the government of Tanzania started to provide free

health care services to its citizens aimed at attaining equity in health care provision

(MOH, 1994). However, the economic crisis in the mid 1970s, increased population

growth, change in disease pattern and increased cost of disease management, reduced

the government ability to continue to provide free health services resulting into

inadequate funding of public health facilities at all levels (MOH, 1996). Inadequate

funding of public health sector led to poor morale of health staffs due to low wages,

shortage of medicines and other medical supplies and deterioration of the health

infrastructure (MOH, 1994).

User fees were the first alternative health financing mechanism adopted in Tanzania

and it was introduced in 1993. Its implementation was done in phases, starting with

referral hospitals and regional hospitals followed by district hospitals, then health

centers and finally dispensaries (MOH, 1999). Introduction of user fees in the public

health facilities provided a big challenge to the majority of Tanzanians because there

were no longer free medical services offered except for pregnant women and under

five years children. This created the demand for introduction of health insurance

schemes for civil servants in the public sectors (MOH, 1997).

In Tanzania, the insurance industry has existed under the monopoly of the NIC. There

has been no formal system of health insurance except for some form of pre-paid plans

6

or self insurance. Through these arrangements, the employers entered into contracts

with private health facilities to provide services for their employees. In certain cases,

organizations ran their own health facilities or clinics.

The NHIF which is a contributory Social Health Insurance Scheme was established

under NHI Act No 8 of 1999. Initially, it was established in order to oversee the system

of service provisional for central government employees only. But in the year 2002,

the law was amended to include other employees in the entire public service. While

the law to establish the fund was enacted in 1999, the fund commenced its operations

on the 1st July 2001 and beneficiaries started to access medical services in October

2001.

The health scheme covers public service employees in the central government, local

government and executive government agencies. The scheme is compulsory in nature

and the contribution rate is 6% of which the employee contributes 3% and the

employer contributes 3%. It covers six people in the family. The beneficiaries include

the principal member, the spouse, four children or legal dependants.

The fund has opened offices in 22 regions of the mainland Tanzania (Kinondoni

municipal, Ilala municipal, Temeke municipal, Mwanza, Mara, Tabora, Kigoma,

Dodoma, Kilimanjaro, Arusha, Tanga, Morogoro, Iringa, Ruvuma, Mbeya, Rukwa,

Mtwara, Kagera, Manyara, Singida, Lindi, Pwani, Shinyanga) and 1 office in Zanzibar.

Up to 31st March, 2012 the fund has been able to offer health care services to 18.2%

of the whole population. This is equal to 6,269,163 members of NHIF and CHF. Also

the fund has registered 5,381 health facilities in the whole country. This is equal to

68% of 7,966 health facilities present in the country. Among them, 4,319 (80%) are

owned by the government, 625 (12%) are owned by religious organizations and 437

(8%) are owned by private sectors (NHIF, 2012).

The government through its party manifesto (CCM, 2010) ordered the fund to increase

the number of members up to 30% of the whole population by the year 2015 in order

to provide health services for all (table 1).

7

Table 1.1: Health Facilities Registered by the Fund Up to March 2012

Source: NHIF Report, 2012

However, despite the good intentions and efforts made by the fund, there are some

indicators which might hinder the fund to operate efficiently and effectively. These

include lack of integrity, lack of knowledge on the concept of health insurance, lack

of knowledge on the procedure for members to access services and for providers to

lodge claims and identify the rightful members, lack of identity cards, sick sheets and

registration forms, unsatisfactory health care services from accredited public health

facilities, narrow benefit package and the restricted coverage of family members,

existence of other simultaneous health financing options such as CHF which creates

confusion as to where should one belong and corruption (NHIF, 2012).

This study found out how health services delivered in Kinondoni municipal health

facilities should be improved.

1.2 Statement of the Problem

Deterioration in the delivery of health care services in public health facilities has been

a critical issue in Tanzania (MOH, 1999). In order to improve performance in the

health care delivery system, the Government of Tanzania adopted health sector

reforms early in 1990’s with the introduction of alternative health financing

mechanism being one of its elements (MOH, 1999). The objectives of financial

reforms in health sector were; to raise additional revenue, improve quality, equity and

Status of the facility Number of facilities Percentage

Hospitals 233 4

Health centers 544 10

Dispensaries 4,202 78

Pharmacies Part 1 134 2

ADDOs 268 5

Total 5,381 100

8

accessibility to health care services and to promote the efficient use of public health

care facilities (MOH, 1994).

Health care services were previously provided free of charge in Tanzania. The

Government was the main provider of health services in the country and the sole source

of health financing. The government expanded health services delivery units by

building dispensaries and health centers in rural areas where the majority of the

population live. However, the problems of implementation of vertical programs,

inappropriate utilization of manpower, improperly functioning referral system,

shortage of staff and inadequate medicines and other medical supplies made the

government to change its role from that of main provider to facilitator of health

services and adopt user fee as alternative health financing mechanism (MOH, 1997).

The introduction of user fee (health insurance) was adopted to overcome the problems

associated with the previous free of charge health care services. The free of charge

health care system made the provision of health services poor because it did not

facilitate effectively and efficiently the flow of resources in the sector, which resulted

in decrease in the availability and quality of health services provided (MOH, 1994).

Literature from Tanzania and other developing countries which were providing free of

charge health care services showed that those services were of poor quality (Mwabu

and Wang’ombe, 1995).

As Norm and Weber (1994) noted, in most of developing countries like Tanzania, the

physical resources are inadequate, inequitably distributed and are of poor quality, staff

in health infrastructures are poorly trained with inadequate resources. In the right

condition, however, insurance may provide equitable method of financing health

delivery system than out of pocket payments. Similarly, MOH (1994) emphasizes that

the introduction of health insurance in the formal sector in Tanzania will improve the

quality, equity, efficiency, effectiveness and accessibility of medical services.

The health services delivery system in Tanzania consists of a network of facilities

starting from dispensary to health center through district and regional hospitals to the

9

referral hospitals. Unfortunately, this system is not functioning as intended due to a

number of factors such as underfunding, weak management arrangements, inadequate

staffing and difficulty in transport and communication (MOH, 2007).

The 2007 health policy recognized the importance of accessible and sustainable

Primary Health Care services for all Tanzanians through provision of a dispensary in

every village, a health center in every ward and a hospital in every district. However,

with the given country size, population and the geographical barriers, the health

services are not accessible to all Tanzanians (MOH, 2008). Furthermore, most

positions in those facilities are not filled with qualified health workers leaving

Tanzania with a severe human resource crisis (MOH, 2008).

Despite the health sector reforms which were deliberately designed to improve health

sector performance, the deterioration in health care service delivery is still going on in

most of the public owned health facilities in Tanzania (MOH, 2008). The researcher

did not come across any previous studies that investigate the delivery of health care

services in Kinondoni municipal health facilities. Therefore, there is a critical need to

fill this gap.

1.3 Research Questions

(i) What are the perceptions of civil servants on health care services

provided in Kinondoni municipal health facilities?

(ii) To what extent has health insurance contributed towards the

improvement of the health care services?

(iii) How can health care services provided in Kinondoni municipal health

facilities (as perceived by civil servants) be improved?

1.4 Objective of the Study

1.4.1 General Objective

To assess the delivery of health care services in Kinondoni municipal.

10

1.5 Specific Objectives

(i) To assess the perception of civil servants on health care services

provided in Kinondoni municipal health facilities.

(ii) To assess the contribution of health insurance towards the improvement

of health care services.

(iii) To elicit civil servants opinions on how to improve health care services

provided in Kinondoni municipal health facilities.

1.6 Significance of the Study

Clients are not only consumers of health services but they also play a great role in

contributing to financial resources which are used in running the health care facilities.

Assessing clients perceptions on health care services will give them an opportunity to

give their opinions on health care services they are provided and what is to be done.

Also, the information obtained from this study will help to inform the policy makers

and health care providers about the health care services as perceived by consumers.

This will enable them to develop and implement appropriate strategies for improving

the health care services provided in Kinondoni municipal health facilities.

Furthermore, the study enabled the researcher to fulfill the requirement for the Degree

of Masters of Public Administration of Mzumbe University.

1.7 Area and Scope of the Study

The study was conducted in Kinondoni municipal. The familiarity of the place was

one of the major reasons, which impressed the researcher to carry out the study.

1.8 Limitations of the Study

There were some challenges in this research which included among others:

(i) Time: the time allocated was short for this research.

(ii) Finance: the researcher was faced with financial constraints due to the fact that

he was self sponsored.

11

Despite that, the researcher put all efforts to accomplish the data collection and

analysis as it was required by the supervisor.

1.9 De – limitations

In order to carry out the research effectively, the research was carried out in Kinondoni

municipal only due to limited time. Furthermore, the area was cost effective to the

researcher.

CHAPTER TWO

LITERATURE REVIEW

12

2.1 Introduction

The increased deterioration in the quality and quantity of health services in the late

1970s and early 1980s sparked out the WB recommendation of increased cost recovery

as part of publicly provided health services in developing countries (World Bank,

1987). In most countries in Sub – Saharan Africa, health care services were provided

free of charge and often with high subsidies from their governments.

Severe shortage in resources such as medicines and other medical supplies finance and

staffs affected the effectiveness and quality of health services leading to the WB

proposition for cost recovery. User fee was taken as a way to improve efficiency and

equity of the health system. Through user fees, clients are provided with the available

health care services at the lower cost and at the same time discouraging excessive use

of resources.

The introduction of user fees (health insurance) in the government health facilities has

been one of the most visible policy changes associated with changes from government

dominated health services to market oriented health services financing provision.

Since government resources were decreased while demand have been increased in

many countries, more private resources have been needed to increase the quality and

quantity of health services (Newbrander and Sacca, 1996).

In order to get loans from the WB and IMF, governments in developing countries were

forced to devalue their currencies and cut back their public expenditure. Throughout

that period of economic crisis, national health expenditure in SSA has been decreased

not only in terms of absolute allocation but also in relation to total budget (Korte,

1992). This has resulted in poor quality of health care, lack of drugs, low resources

allocation and low morale to some of health providers in health facilities. In some

areas, the essential health services ceased to function.

The tangible benefits of cost recovery in government health services must include the

change of previous poor condition to what the community is able to discern as an

improvement in the service. Revenues can be used to expand the available services by

freeing resources or financing services that are under financed, for example medicines,

13

medical supplies, rehabilitation and increasing morale of service providers. Efficiency

is increased through reduction of excessive use of services, but increasing capacity

according to the need of the clients.

The social health insurance is based on mutual support and involves a transfer of

resources from relatively richer and healthier people to relatively poorer and sicker

people. It works best when there is a consensus among the population that mutual

support is a good thing (Norm and Weber, 1994).

Countries that have started user fees differ in the emphasis they put on the mobilization

and use of such fees. User fee survey by the WB in various countries in SSA revealed

a number of countries participating in the user fee scheme. Out of 27 countries, 30%

saw the revenue collection as a primary objective. The rest apart from collection of

revenue put emphasis on improving primary health care services including staff

incentives and drugs procurement (Shaw, 1995). Moreover, mobilization of user fee

without targeting improvement of health services quality cannot convince the client on

the need of user fees.

According to Nolan and Turbat (1993), health insurance should encourage clients to

move across the various levels of referral system without bypassing other levels.

Clients feel secured when they are referred officially to the next level. Only the right

signals are able to enhance improvement in quality using the user fees. When there is

an escalating user fee charges coupled with improved quality, then individuals are

given incentive to enter the health system. At the higher level, they pay more but they

also expect more in terms of expertise and efficiency.

The effectiveness of health insurance as a method of improving quality depends on its

ability to purchase the services that are being offered. Health insurance that had been

eroded by inflation is unlikely to contribute toward the goal in improving the quality

of health services. For health insurance to be effective, it must be adjusted to keep pace

with inflation as observed in Ghana, Zambia and Zaire (Shepard et al, 1995).

14

Poorly structured health insurance for services has been criticized due to failure to

portray the right picture in terms of value for money and thus negatively affecting the

amount of revenue generated from user fees. Each client would like to perceive the

exact value of service one is paying for. Flat user fees, although are simple in

administration, are unpopular and do not help clients to appreciate the value of the

services provided. A flat user fees in Uganda was also associated with frequent

shortage of drugs and staffing as it elicited a negative response by the community

(McPake et al, 1992).

2.2 Theoretical Perspectives

2.2.1 Market Failure

Market fail when it is possible to make one person better off without making someone

else worse off, thus indicating inefficiency (Winston, 2006). Market failure is a

concept within economic theory where the allocation of goods and services by a free

market is not efficient. There is the problem which prevents the market from operating

efficiently. Market failure refers to a situation where the market in theory is supposed

to function but may fail to do so in practice. Market fails to allocate resources

efficiently and produce socially optimum amounts of goods and services over time

when at least one of its components does not function well. The prevalence of market

failure is due to lack of conviction in favor of markets, the inflexibility of intervening

government agencies and political forces that enable certain interest groups to benefit

at the expense of society as a whole (Winston, 2006).

In health care market, the illnesses and the diseases of the patients, and their treatments

and investigations are the commodities that are traded. Thus, illness and diseases and

their investigations and treatments have a market value. Kenneth (1963) identified that

health care is inherently subject to market failure. While the government might be able

to improve some of the institutional and organization deficiencies, it will not be able

to improve all market deficiencies since some of the problems facing the government

are similar to those facing the market (Stiglitz, 1989).

15

2.2.2 Government Failure

Government fails when an intervention is unwarranted because markets are performing

well or when the intervention fails to correct a market problem efficiently (Winston,

2006). Government failure is the public sector analogy to market failure and occurs

when a government intervention causes a more inefficient allocation of goods and

resources than would occur without that intervention. Some types of government

interventions such as taxes, subsidies, price control and regulations including attempts

to collect market failure may also lead to an inefficient allocation of resources which

may make the matter worse rather than better.

Just as market failure, government failure is not a failure of the government to bring

about a particular solution, but is rather a systemic problem which prevents an efficient

government to provide a solution to the problem. The existence of market failure is

sometimes used as a justification for government intervention in a particular market.

Wolf (1979) emphasized that the possible existence of market failure is not sufficient

to prove the certainty of government success. According to Wolf, government may

also fail due to externalities and private goals, redundant and rising costs and

distributional inequity due to influence and power of interest group. The government

policy can be improved by making greater use of market oriented situations that have

already produced benefits in certain situations. ‘If the markets don’t like your policies,

they will punish you’ (Blair, 2004).

2.3 Quality of Health Care Services

According to the 2009 – 2015 Health Sector Strategic Plans III, quality in health

services is working according to specific standards which aim at improving the health

status of individuals and communities, reducing suffering due to diseases and illnesses

and increasing client’s satisfaction. At the same time efficiency and effectiveness is

increased (URT, 2008). Edvardsson (1998) emphasized that the concept of service

quality should be approached from the customer’s perception. It is the customer’s

perception which determines the level of service quality and satisfaction. Therefore,

the customer is the best judge of the quality of service and not the service provider.

16

Parasurman et al (1988) proposed five dimensions of factors affecting service quality,

those were: tangibles that include the physical appearance of the service facility,

equipments, service personnel and communication materials; reliability to deliver the

promised service dependently and accurately; responsiveness which refers to

willingness of the service provider to be helpful and prompt in providing service;

assurance that refers to the knowledge and courtesy of employees and their ability to

inspire trust and confidence; and empathy which is the customer longs for compassion,

caring and individualized attention from the service provider. Similarly, Brown et al

(1991) drew insight from Parasurman et al (1988) and developed six dimensions to

explain service quality. These dimensions are: technical competence which refers to

the degree to which health workers are trained and communicate with client’s; access

to service; affordability; interpersonal relation; reliability and tangibility (table 2.1).

Table 2.1: Dimensions of Quality Health Service

Dimension Details

TECHNICAL COMPETENCE The degree to which health care personnel have

the training and ability to assess, treat and

communicate with clients.

ACCESS TO SERVICE Being accessible and easy to contact in term of

distance from place of residence and availability

of service.

17

AFFORDABILITY Service affordable in term of client’s ability to

pay for service. Affordable service provides the

greatest benefit within the resources available.

INTERPESONAL RELATION Good interpersonal relation establishes trust and

credibility through demonstration of respect,

politeness, confidentiality, courtesy,

responsiveness and empathy.

RELIABILITY Client receives the complete range of health of

that he/she needs without interruption, cessation

or unnecessary repetition of diagnosis and

treatment. Services must be offered on an

ongoing basis and near the place of residence.

TANGIBILITY Relates to the physical appearance of facilities,

availability of personnel, and materials as well as

to comfort, cleanliness and privacy.

Source: Adopted from Brown et al, 1991

The relevance of the above health quality elements that have been reflected in various

health sector initiatives in Tanzania is depicted in figure 2.1 which suggests that quality

dimensions affects positively or negatively the delivery of health services.

Figure 2.1: Health Quality Dimensions Relationship

TECHICAL

COMPETENCE

ACCESS TO

SERVICE

AFFORDABILITY

QUALITY

HEALTH

SERVICE

Clients

are

Satisfied

with the

Quality

of

Health

Services

Offered

18

INTERPERSONAL

RELATION

RELIABILITY OF

SERVICES

TANGIBILITY

Source: Adopted from Shillingi and Mutalemwa, 2012

Following the introduction of alternative health financing mechanisms, measurement

of quality in government health facilities has received a great attention in SSA. This is

based on assumption that introduction of user fees in the previously free health care

services can only be successful and acceptable if quality of health care is also improved

at the same time (Litvack and Bordat, 1993).

Donabedian (1997) introduced a conceptual frame work for assessing quality which

uses the elements of structure, process and outcome. Structure attributes include the

setting in which care occurs. Structural aspect of quality includes physical states of

building, availability of equipments, medicines and other medical supplies, range of

services available, number of qualified staffs and other organizational activities (table

2.2).

Table 2.2: Conceptual Framework for Assessing Health Service Quality

Element Description

STRUCTURE Physical states of buildings, availability of medicines,

medical supplies and equipments, range of services

available, number of qualified staffs and other

organizational activities.

19

PROCESS All activities associated with providing and receiving care

and include technical competence of service providers,

interpersonal skills, maintenance of privacy and

confidentiality.

OUTCOME Changes in health status, the improved quality of life and

client’s satisfaction achieved through inputs and

processes of care.

Source: Donabedian, 1997

However, availability of medicines at the health facility is usually perceived as the

most important measure of quality in many communities, though this may be different

in some communities (Msamanga et al, 1996). For example, a study done in Zambia

revealed that people criticized user fee because it did not improve the quality of health

care services in terms of drugs availability (Van der Geest, 2000). Similarly, the study

done to assess perceived quality of care in primary health care services in Burkina

Faso, showed that despite introduction of alternative health financing mechanisms,

clients were not satisfied with the adequacy of resources and services, particularly the

availability of drugs (Baltussen et al, 2001). In Cameroon, it was also found that

utilization of services in public health facilities had increased significantly after the

introduction of user fees and this was due to improved quality of health services

particularly on the availability of drugs (Litvack and Bodart, 1993).

In a study done in Bagamoyo district in Tanzania, 63.6% of patients interviewed

reported that despite the introduction of user fees, shortage of drugs was one of the

main problems that affected quality of health care (Mallya, 2004). A similar situation

was reported in Tanga where it was observed that 23.6% of patient interviewed were

no satisfied with the quality of health care services because they could not get all the

drugs prescribed because they were out of stock in public health facilities (Maier and

Urassa, 1997).

Another element of structural aspect of quality that determines clients’ perception on

quality of health care is the physical state of health facility buildings. In a study done

20

in Bagamoyo district, 65.4% of the clients interviewed reported that the introduction

of user fees has little positive impact on the state of hospital buildings in terms of

cleanliness and maintenance (Mallya, 2004). Similarly, in the study done in Tanga it

was observed that some of the buildings had collapsed due to lack of regular

maintenance (Maier and Urassa, 1997). In most instances, structural aspect of quality

care had been evaluated in terms of physical condition of facility buildings and

availability of adequate equipment and drugs. However, the organizational aspects

such as number of staffs, qualification of staffs, administrative and managerial

procedures are also important. This is due to the fact that poor quality of health care

services can also be contributed by poor performance of health workers due to lack of

knowledge, inability to translate sufficient knowledge acquired through training into

appropriate attitude and performance, and low staff morale and motivation caused by

meager wages and poor working environment.

Process is another aspect of quality. It refers to all the activities associated with

providing and receiving care and include technical competence of service providers,

interpersonal skills, maintenance of privacy and confidentiality (Donabedian, 1980).

The technical aspect of quality refers to how well medical science and knowledge are

applied to the diagnosis and treatment of medical problems. Beyond technical aspect,

interpersonal aspect of quality of health care service is an essential part of the process

of health care provision. It refers to interactions between client and provider, in which

friendliness, attentiveness of health care providers and effective communication skills

has critical impact on client satisfaction with quality of health care services

(Donabedian, 1980).

Studies has shown that, in some countries, lack of respect for patients, stigmatism and

abusive language of health providers towards patients is still a big problem even after

the introduction of alternative financing mechanisms (Van der Geest, 2002). However,

provider – client interaction does not only involve attitude of health providers but also

the process of interaction such sharing of information and privacy. In most of primary

health care facilities, privacy has been reported to be poor due to inadequate space for

counseling and examination (MOH, 2001).

21

Outcome is another measure of quality of health care services. It includes the changes

in health status, the improved quality of life and clients’ satisfaction achieved through

inputs and processes of care. However, changes in health outcome have proven to be

difficult to measure instead many studies have been used clients’ satisfaction as an

important measure of outcome aspect of quality care. Clients’ satisfaction occurs when

services experienced meet clients’ expectations. To the great extent it is related to

aspects that are not strictly medical or technical but mainly on interpersonal aspects.

Many studies have been done to assess the impact of user fees on the quality of health

care services. However, there is still mixed evidence from African countries that user

fees contribute to the improvement of quality health care. In some countries, evidence

indicates that fees improved quality of care and patients attendance in public health

facilities, while in some areas user fees are reported to have caused utilization of health

care services. Assessment of equity implication of health sector user in Tanzania found

that there is limited positive evidence that user fees have in general achieved their

objectives of sustainability, drug availability, quality care, equity and access to the

poor. Members of NHIF have also shown concerns on poor patient – providers

interactions, long waiting time and shortage of drugs as the main problems which have

led dissatisfaction with quality of health care services (NHIF, 2012).

2.4 National Health Policy

The national health policy aims at implementing national and international

commitments. The overall objective of national health policy in Tanzania is to improve

the health care well being of all Tanzanians with the focus on those most at risk to

reduce morbidity, to raise the life expectancy and to encourage the health system to be

more responsive to the need of the people. The vision of the Government is to have a

healthy society, with improved social well being that will contribute effectively to

personal and national development. The mission is to provide basic health services in

accordance to geographical conditions which are of acceptable standards, equitable,

quality, affordable, sustainable and gender sensitive (MOH, 2009).

22

Specifically, the government aims to; reduce morbidity and mortality in order to

increase the life span of all Tanzanians by providing quality health care; ensure that

basic health services are available and accessible; prevent and control communicable

and non communicable diseases; sensitize the citizens about preventable diseases;

create awareness to individual citizens on their responsibility on health; improve

partnership between public sector, private sector, religious institutions, civil society

and community in provision of health services; plan, train and increase the number of

competent health staff; identify and maintain the infrastructures and medical

equipments and review and evaluate health policy, guidelines, laws and standards for

provisional of health services (MOH, 2009).

The government has developed a number of enabling policies and environment as an

effort to strengthen the health services in the country. These enabling policies are both

national and international commitments like Tanzania Development Vision 2025,

National Strategy for Growth and Reduction of Poverty, and Millennium Development

Goals. In TDV 2025, the main objective is achievement of high quality live hood for

all Tanzanians. The MOHSW contribute towards the improvement of health status life

expectancy of the people of Tanzania. This is partly achieved through public health

interventions and primary health services. Under MDG, the government is required to

reduce child mortality by two-thirds and improve maternal health by reducing maternal

mortality rate by three-quarters from 1990 to 2025, also to combat HIV/AIDS, malaria

and other diseases. NSGRP places MDG’s within cluster II which addresses

improvement of the quality of life and social wellbeing (MOH, 2009).

2.5 Health Delivery System in Tanzania

The health service delivery system in Tanzania consists of a network of facilities which

assumes a pyramidal structure starting from a dispensary, health center through the

district and regional hospitals to referral hospitals. In principle, the referral system is

designed for the dispensary to refer patients to health centers and for the health centers

in turn to refer into hospitals (figure 2.2). Unfortunately, this system is not functioning

as intended due to a number of factors such as underfunding, weak management

23

arrangements, inadequate staffing and difficult in transport and communication

(MOH, 2007).

Figure 2.2: The Health System in Tanzania

Referral Hospital Services

National and Regional Referral

Hospitals

Council Health Services

Primary Health Care and First Level Hospital

Services

Public and private Health Care Providers

National

Support

Services

24

Source: Ministry o f Health and Social Welfare, 2008

Tanzania Mainland is divided into 24 administrative regions and 115 districts with

133 councils. There 10342 villages. Primary health care forms the basis of the

pyramidal structure of health care services. There are 4679 dispensaries and 481 health

centers. About 90% of the population lives within 5km of a primary health facility.

There are 55 district hospitals owned by the government and 13 designated district

hospitals owned by FBO’s. Furthermore, there are 86 other hospitals at first referral

level owned by the government, parastatals and private sectors. There are 18 regional

hospitals functioning as referral hospitals for district hospitals and 8 consultancy and

specialized hospitals in the country (MOH, 2007).

Government staffing norms for health facilities exist but only 35% of the positions are

filled with qualified health workers leaving Tanzania with a severe human resources

crisis (MOH, 2009). The 2007 Health Policy recognize the importance of accessible

and sustainable Primary Health Care services for all Tanzanians through provision of

dispensary in every village, a health center in every ward and a hospital in every

district. However, with the given country size, population and the geographical

barriers, the health services are not accessible to all.

In order to achieve its goals, Tanzania has decentralized many government functions

through Decentralization by Devolution. Local Government Authorities are

responsible for delivering public services in local health, education, water and

agriculture. The MOHSW and PMO-LAG in collaboration with Public Service

Management Office are responsible for recruitment and distribution of staff throughout

the country (figure 2.3).

25

Figure 2.3: Ministries, Departments and Agencies Most Involved in Health Sector

and their Responsibilities

26

Source: Ministry of Health and Social Welfare, 2008

2.6 Health Sector Reforms

Health sector reforms have been taking place in most of developing countries in order

to address problems of inefficiency, ineffective, poor accessibility of health services

Government

of Tanzania

PMO-RALG Ministry of

Finance and

Economic Affairs

Government and

Holding Accounts

Universities and

Colleges

Disbursement

of funds,

financial

reporting

Reporting

Training of

health staff

staff

Ministry of

Education and

Vocational

Regional

Hospitals and

RHMTs

Local Government

Authorities

Provision of

primary health

and hospital

services

Contract

Private

Health

Providers

Provision of

health

Services

Support

functions in the

health sector

National and

Specialized

Hospitals

Departments and

Agencies,

Training Centers

MOHSW

Training of health

staff

27

and growing concern of financial sustainability. The driving forces behind health

sector reforms were the economic crisis which occurred in the late 1970s and early

1980s due to tremendous increase in oil prices, rising interest rates of external debts

and falling of other commodities which made African countries and other developing

countries unable to repay their foreign debts. In order to solve these problems, African

countries and other developing countries signed an agreement with the WB and IMF

to adopt SAP, which recommended cutbacks in government expenditure on health

sector and other social services (World Bank, 1993).

The dramatic drop in health expenditure in 1980s and 1990s in developing countries

led to fall in the economic and social developments attained in the past two decades,

which were characterized by increased number of health professionals employed in

public sector, improved infrastructure and extension of health care. For instance,

before the implementation of SAP in Tanzania, the government had succeeded in

expanding access to health care national wide. By 1977, more than three quarters of

Tanzanians population lived within 5km of a health facility, but after implementation

of SAP under funding occurred in the health sector leading to poor performance.

In order to generate resources for health sector and attain better quality and more

efficient and effective health care system, the WB agenda for reforms was launched as

well as the promotion of Bamako initiative of 1987 by UNICEF and WHO. In its

agenda for reform, the WB emphasized the need for introduction of cost recovery

strategies (World Bank, 1993). This included introduction of user fee for health

services that were previously provided free of charge and promotion of Health

Insurance Schemes or Prepayment Schemes (Green, 1992, World Bank, 1993). The

objectives of Bamako initiative were to improve quality of services and ensure equity

in access of care through community participation in form of payments for drugs and

development of community management capacity (Russell and Gilson, 1997).

In response to WB recommendations to adopt cost recovery and the Bamako initiative,

various countries in SSA and the rest of developing countries introduced user fees into

their health sector by the mid 1990s. A survey done by the WB in 1993 reported that

28

out of 37 African countries, 33 of them had cost recovery policies for the public sector

(Nolan and Turbat, 1995). Although in public health facilities user fees were

introduced in the last decade, they had been used in private and voluntary owned

organizations in most of developing countries for a long time ago even before the WB

recommendation to adopt cost recovery in health services (Shaw, 1995).

Experience shows that alternative health care financing schemes can succeed in

achieving their goals only if government takes complementary measure to ensure that

the services are accessible to all people and are of reasonable quality and that the

generated revenue is properly managed and reinvested to improve the quality of health

care services. However, studies show that these conditions are rarely met in practice.

It has been revealed that in some cases user fees revenues have not been retained within

the health sector, but goes to other local uses.

In Tanzania, the health sector has undergone continuous reforms since independence.

The Arusha Declaration of 1967 advocated for the development of a health service that

limited the role of the private sector, advocating for free medical services and placed

emphasis on rural development (MOH, 1997). During the period of the 70’s the

Government developed and extensive health services delivery infrastructure that

extended into the rural areas delivering curative, preventive and promotive services

through a network of hospitals, health centers and dispensaries. The health services

delivery was supported by health manpower training institutions.

Despite this extensive health services delivery infrastructure, health indicators did not

improve sufficiently. The cost of running this extensive health service in light of the

increasing cost for medicines, medical supplies and equipment and the deteriorating

economy was impossible for the government to meet. In additional the system faced

managerial and organization problems that decreases its efficiency (MOH, 1997).

In 1994 the MOH embarked on a more systematically planned HSR and aims at

improvement of access, quality and efficiency health services delivery. Primary Health

Care was adopted as the most cost- effective strategy to improve the health of the

29

people. The major focus of HSR is therefore on strengthening the District Health

Services as well as strengthening and reorientation of secondary and tertiary services

delivery in hospitals in support of primary health care (MOHSW, 2007).

The health sector reforms are in the following dimensions: decentralization of health

services; financial reforms, such as enhancement of user-charges in government

hospitals, introduction of health insurance and community health funds and

Public/Private Partnership reforms such as encouragement of private sector to

complement public health services. They also include organizational reforms such as

integration of vertical health programs into the general health services and propagation

of demand oriented researches in the health sector (MOHSW, 2007).

2.7 Health for All (Universal Coverage)

Universal coverage is a situation whereby society is covered with needed health

services for all people and at an affordable cost (Bayarsaikhan, 2006). This is known

as equity in accessing health care services. Accessing health care services is often

interpreted as securing services to everyone when they need irrespective of income,

sex, age or social status. Universal coverage is also associated with equity in finance

implying that households contribute on the basis of ability to pay.

In order to achieve universal coverage, organizational mechanisms are needed to

collect financial contributions equitably and efficiently to pool those contributions so

that financial risk associated with the need to pay for care are shared by all and to

purchase or provide effective and cost effective interventions with those contributions

(Preaker, 2005).

Historical perspective and social choices have been used by different countries to

determine which type of system forms the basis, but the important characteristics of

social protection. One indicative factor that needs to be considered by policy makers

is the degree of prepayment and pooled plans vis-à-vis the out of pocket spending. If

out of pocket is still the dominant method of financing health care, then a particular

society is still at a beginning of its universal coverage route. Countries that have

30

achieved universal coverage are South Korea, Japan, Germany, Australia and

Phillipines (table 2.3).

Table 2.3: Countries that have Achieved Universal Coverage in the World

Country Years taken to reach the coverage

South Korea 12

Japan 36

Phillipines 76

Germany 100

Source: NHIC South Korea 2008

There is however no definite transitional period to achieve universal coverage. While

the Germany took 100yaers, South Korea took 12 years. African countries which have

achieved universal coverage though not to a great extent are Rwanda, Morocco, Ghana

and Kenya (table 2.4).

Table 2.4: Implementation of Universal Coverage in African countries

Country Population Percentage covered

Rwanda 10,186,063 91%

Morocco 34,343,220 77%

Ghana 23,382,848 60%

Kenya 37,983, 840 21%

Source: CIA The World Fact Book 2008 on Population Estimates

2.8 Health Expenditure and Financing in Developing Countries

Health expenditure accounts for 5 – 10% of government expenditure in developing

countries. In spite of this, there is still pressure to increase health expenditure in this

period of declining public sector resources availability in most of developing countries.

The financing of health care has therefore become increasingly critical issue in most

of developing countries particularly in SSA (Korte, 1992). As many governments in

developing countries face growing constrains on availability of resources to finance

31

health care, efforts to seek alternative forms of financing have intensified. Typically,

alternative methods of financing health services include providing insurance or other

coverage, charging users of health facilities, greater cooperation with private and the

effective use of non-governmental resources.

The main options are compulsory health insurance, community fund and user charge

(Smith and Rawal, 1992). Governments should supplement tax revenue by increasing

direct households contribution to the health sector through a variety of policy reforms;

user fees at government facilities, the adoption or encouragement of community based

financing schemes and the encouragement of not for profit making but fee charging

non-governmental organizations.

2.9 Health Insurance Schemes

Currently, the focus of international community is on the need to move away from out

of pocket payment as a source of health financing towards health insurance schemes.

The types of health insurance schemes include; Social Health Insurance Schemes in

which contributions are based on payroll deductions, with employee and employer

contributing to the premium set. The second type is Community Based Health

Insurance Scheme. This is not linked to the employment status but premiums are

commonly set according to risk faced by average number of the community.

Enrollment in these schemes is voluntary in nature. The third type is Private Insurance

Schemes where people pay premiums related to expected cost of providing services to

beneficiaries. In this type, people at high risk pay more than those at low risk (Bennet

and Gilson, 2001).

However, in developing countries, health insurance schemes are still confined to a

minority of population and only few countries have considerable experience in setting

up micro-health insurance. These countries include Burkina Faso, Mali, Ghana and

Senegal. In Tanzania as stated earlier, the first health financing option was User Fees

adopted in 1993, followed by Community Health Fund which was introduced in 1996

and finally National Health Insurance Fund which started to operate in 2001.

32

2.10 Health Financing in Tanzania

Health services financing mechanisms in Tanzania includes Central and Local

government funds, religion organizations, voluntary agents and donors. Other

financial sources are community contribution, community health funds, user fees and

national health insurance fund (MOH, 2002).

(a) Central Government Funds

The central government finances health sector in two ways:

(i) The ministry of health provides funds to referral hospitals and various medical

schools. It also provides funds to its parastatals such as NIMR. The ministry

also gives subventions to Kilimanjaro Christian Medical Center, Bugando

Medical Center and Designated DistrictHospitals.

(ii) The Prime Minister’s Office provides funds to run regional and district

hospitals including salaries for employees. At the same time, the office gives

subventions to the local council for running the health centers and dispensaries.

(b) Local Government Funds

The local governments are responsible for running health centers and dispensaries in

rural areas. They provide funds for purchasing of medicines and other medical

supplies, salaries, training and development of employees, constructions and

maintenance of health centers and dispensaries. They get their funds from government

subventions and local taxes.

(c) Religious Organizations and Voluntary Agencies

Religious organizations and voluntary agencies run their health facilities through their

own funds and service charges. The government provides subsides to these

organizations.

33

(d) Donors Funds

Some countries and International Organizations help Tanzania in provision of health

services in different forms. Most donors provide their funds to the MOHSW for

running national, regional or district health projects. Other donors help by bringing

their experts and offering medical supplies. Such assistances are through international

organizations like WHO etc.

(e) Community Contributions

Community contributions are mainly in cash. These are:

(i) User Fees

Communities contribute through user fees or cost sharing in health facilities

complements the government financing. Exemption is granted for old ages of more

than 60 years old, pregnant women and children under five years old.

(ii) Community Health Fund

Community health fund is recognized as an effective tool for mobilizing voluntary

community involvement and participation in supporting health care. It provides an

opportunity for seasonal income earners in the informal sector to pay for their services

before they fall sick.

(iii) National Health Insurance Fund

This is a mechanism to ensure medical protection in the formal sector.

According to section 4(2) of the Act, the main objectives of establishing the fund are;

to establish a reliable system that will enable the public sector employees to contribute

towards their health care services and that of their families, to promote public private

partnership that would instill competition which would in turn lead to improvement of

both accessibility to and quality of health services which is the essence of instituting

health reforms in Tanzania, and finally to expedite improvement of the health sector

by putting in place an alternative health financing option that would complement the

government health budget and hence reducing the financing gap.

34

2.11 Effects of Costs on Health Seeking Behavior

People perceive illness differently. The perception is an important determining factor

in seeking health care. An individual or households has to undergo several decision

making process before conclusion. These decision making processes are divided in

three stages. First, awareness of the presence of illness in the family will make them

to decide or not to seek health care services. Secondly, the type of health care provider

has to be decided upon and their various provider alternatives including self care and

decision on which one to go has also to be made. Lastly, the patient has to decide

whether or not there is a need to seek further treatment if cure is not affected after a

period of time.

Apart from making decision to where to seek care, there are factors that can determine

demand for health care. Researchers have shown that these factors include age, gender,

income, education and employment status, type and severity of illness, cultural factors,

distance and cost in time in reaching medical facility, time spent in waiting to get

medical care at the facility and quality of care offered. The availability of drugs,

medical supplies and competent staffs are supply side factors (Ellis and Stephenson,

1992).

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter focuses on the methods and instruments that were used to collect and

analyze data. It starts by describing the study area, research design and population of

the study. Sample size and data collection instruments are also discussed. The chapter

concludes by discussing the approaches to data collection and analysis.

35

3.2 Study Area

The study was conducted in Kinondoni municipal. The municipality has a total area of

531 square kilometers. According to the 2012 census, the municipality has a

population of 1,775,049 with a population growth rate of 5.0% per annum and

population density 3,343 people per square kilometer. Administratively Kinondoni is

broken into 4 divisions, 27 wards and 113 sub-wards.

Kinondoni municipal was selected for the study mainly due to its conveniences to the

easiness of communication, cost effective and limited time. Furthermore, Kinondoni

is divided into urban, sub – urban and villages which are inhibited by all classes of

people, from the richest to the poorest.

3.3 Study Design

A research design is a conceptual structure within which research is conducted; it

constitutes a blueprint for the data collection measurement and analysis (Cooper and

Schindler, 2003). It also refers to the way a study is planned and conducted, the

procedures and techniques employed to answer the research problem or questions

(Kothari, 2004).

A cross sectional study was employed in this research which was conducted in

Kinondoni municipal health facilities in April 2013. A cross sectional study is one that

studies a cross – section of the population at a single point in time, and data collection

is done once (Adam and Kamuzora, 2008). These are studies which are not repetitive

in nature and are carried out once at a particular point in time. Cross sectional study

was preferred by the researcher due to time constraint. Qualitative approach was used.

3.4 Study Population

A population is a collection of all elements to be studied and about which one want to

draw conclusion (Levin and Rubin, 2002). It also refers to the totality of objects under

investigations. The term population is not only applicable to human beings but to any

case of interest in the study (Adam and Kamuzora, 2008). The study population

36

consisted of civil servants attending health facilities in Kinondoni municipal who paid

health care services through NHIF.

This population was selected because other studies have indicated the need for

assessing the contribution of user fees in delivery of health services in public health

facilities. For example, Mallya (2004), in a study done in Bagamoyo district revealed

that, despite the introduction of user fees, shortage of drugs was one of the main

problems that affected quality of the health care services.

3.5 Sample and Sampling Technique

A sample is a group, hopefully representative of the population that is studied and from

which one derives generalizations about the population (Adam and Kamuzora, 2008).

The exact number of items selected from a population to constitute a sample is called

sample size. Sample size is the number of representative selected for interview from a

research population. In this study, stratified random sampling technique was used to

select the sample from the targeted population.

Stratified random sampling technique is a modification of simple random sampling

and systematic sampling that is designed to produce more representative and accurate

samples where a population comprises distinct groups (Adam and Kamuzora, 2008).

In stratified random sampling, the population is stratified into a number of non-

overlapping sub-populations or strata and sample items are selected from each stratum

based on simple random sampling (Kothari, 2004).

In this study, the targeted population was divided into different groups or layers before

selection of the representative in order to ensure representation of all members in the

population with similar characteristics such as gender, age group, marital status and

education level were stratified in the same stratum and then randomly selected. A total

number of 100 respondents attending the health facilities to receive health care services

were selected to form the sample; 20 respondents from Lugalo, 20 from

Mwananyamala, 20 from Sinza, 20 from Magomeni and 20 from Tandale.

37

3.6 Data Collection Instruments

Data were collected daily from 8.00 am to 4.00 p.m except for weekends and holidays

for the period of four weeks. The data collection instruments were questionnaires with

both open and closed ended questions, interview using hospital checklists and personal

observation in health facilities. Secondary data were obtained through library study,

journals and internet.

3.6.1 Questionnaire

Questionnaire is a series of questions each one providing a number of alternative

answers from which the respondents can choose (White, 2002). Quite often,

questionnaire is considered to be the heart of cross- sectional studies. This is because

apart from being cheaper to administer, questionnaire facilitate conveniences of

reaching respondents who are not easily reachable and provide respondents with time

to give well thought out and objective answers (Kothari, 2004). To be successful, the

questionnaire should be comparatively short and simple. Questions should proceed in

logical sequence moving from simple to more difficult questions (Kothari, 2004).

Based on that, simple and understandable questionnaires with both open and closed

ended questions were constructed. Copies were made and given to respondents who

were attending the health facilities to get treatment. They were provided with adequate

time to give answers. Finally filled questionnaires were collected.

3.6.2 Interview

The method of collecting information through personal interview is usually carried out

in a structured way. Such structure interview involves the use of set of pre-determined

questions and of highly standardized techniques of recording. A structured interview

guide is prepared to capture more information in great depth from key informants

(Kothari, 2004). This study used facility checklist because the idea was to capture more

detailed information on health services delivery. The scheduled visits to heads of

departments in the five municipal health facilities under the study were prepared and

prior appointment for interview was made.

38

3.6.3 Observation

When observation is used as data collection tool, the information is sought by way

investigators’ own direct observation without asking from respondent hence subjective

bias is eliminated and information relate to what is currently happening (Kothari,

2004). Another equally important reason for using observation in the study was that,

it gives an opportunity to gather live data from live situation (Cohen, 2000). In this

study, observation aimed at collecting data on physical state of buildings, general

cleanliness of the buildings, consultation, rooms and environmental cleanliness of the

facility surroundings.

3.7 Data Analysis

After collecting data from the field, raw data were edited and correction made on

obvious errors such as entry in a wrong place. In case of inappropriate or missing

replies, proper answers were determined by reviewing other information in the

questionnaire as proposed by Kothari (2004). Editing involved step by step, sorting

and checking of collected data to determine the relevant and irrelevant data and to

arrange them in a proper way to make easy presentation. After these validity and

reliability checks have performed, data were coded in different categories so as to

simplify the analysis and eventually were entered into computer spreadsheets.

Thereafter, data entered into Microsoft Excel software for summarization and

interpretation. The analysis was conducted based on the data from and information

collected from primary and secondary sources. The analyzed data were presented in

tables for easy interpretation and conclusion drew.

39

CHAPTER FOUR

PRESENTATION OF FINDINGS

40

4.1 Introduction

The purpose of this chapter is to present and analyze data obtained in the field in

simpler measures of statistics so that the data can be interpreted and understood by the

majority of people. The data presented in this chapter answers the research questions.

4.2 Respondent Interview

A total number of 100 civil servants attending municipal health facilities in Kinondoni

municipal were interviewed, 20 respondents were from Mwananyamala hospital, 20

from Sinza hospital, 20 from Lugalo hospital, 20 from Magomeni health center and 20

from Tandale dispensary. All were members of NHIF.

Table 4.1 shows that, a higher proportion of the sample study was males (55%). Most

of the respondents were either married (70%) or single (28%). About 44% of

respondents interviewed were in the age group of 40 to 49 years, those aged above 50

years contributed only 5 % of the total respondents. Respondent in the secondary

education (49) category formed the majority (49%) of the study sample.

Table 4.1: Socio-Demographic Characteristics of Respondents Interviewed

Characteristics n (%)

Sex

Male 55 55

Female 45 45

41

Total 100 100

Age group (years)

20 – 29 33 33

30 – 39 18 18

40 – 49 44 44

> 50 5 5

Total 100 100

Marital status

Single 28 28

Married 70 70

Divorced 1 1

Widowed 1 1

Total 100 100

Educational status

Primary education 6 6

Secondary education 49 49

Post secondary education 45 45

Total 100 100

Source: Field data 2013

Respondents were asked to give reasons why they decided to get health care services

at the facility they had attended. Fifteen percent of the respondents mentioned short

distance as their main reason for seeking health services care at the municipal hospitals

they attended, while 46% stated that it was because of the good quality of health care

services that were provided. A slight proportion of respondents, 9% mentioned that

they were given referral, while 25% mentioned they were directed by a friend/relative

and 5% stated that their friends/relatives works there (see table 4.2).

Table 4.2: Reasons for Choice of Health Facility

Reasons for choice n (%)

Close to where I live 15 15

Good quality of care 46 46

42

I was given a referral 9 9

Directed by a friend 25 25

Relative works there 5 5

Total 100 100

Source: Field data 2013

Table 4.3 shows that a large proportion of respondents who attended the Kinondoni

municipal health facilities, used public transport by 72%, followed by those who

walked (18%) compared to other means of transport. This is possibly because most of

civil servants who were in middle income attend public health facilities.

Table 4.3: Mode of Transport Used By Respondents to Attend at the Health

Facilities

Mode of transport n (%)

Public transport 72 72

On foot 18 18

Taxi 5 5

Others (Private car) 5 5

Total 100 100

Source: Field data 2013

Table 4.4 revealed that the majority of interviewed respondents (55%) reported that

drugs were sometimes available at the municipal hospital they attended, while a small

proportion (7%) said that drugs were not available, (12%) accepted that drugs were

always available at the health facilities they attended and 26% reported that drugs were

available.

Table 4.4: Respondents’ Perception on Drug Availability at the Health

Facility

Clients perception n (%)

Always available 12 12

43

Available 26 26

Sometime available 55 55

Not available 7 7

Total 100 100

Source: Field data 2013

Respondents’ opinions on provider-client interaction were assessed in the following

areas: health providers’ attitude towards patients, adequacy of consultation time and

information exchange during consultation. Fifty one percent of the interviewed

respondents responded that, they were satisfied with the attitude of health providers at

the five municipal health facilities. Only 9% of the respondents perceived that the

attitude of health providers toward them as being poor while 14% of respondents

perceived the attitude of health care provider as being very satisfactory ( table 4.5).

Table 4.5: Respondents’ Perception on Health Care Providers’ Attitude

Respondents’ perception n (%)

Very satisfactory 14 14

Satisfactory 51 51

Neutral 26 26

Poor 9 9

Total 100 100

Source: Field data 2013

Respondents were asked to give their opinions on the extent they perceived the

adequacy of the time they had spent with the health care providers to explain the health

problems. Forty four percent responded that they had been given adequate consultation

time, while 22% responded that they were given inadequate time, 18% reported the

time to be very short, 8% reported the time to be too long and 8% were neutral (table

4.6).

Table 4.6: Respondents’ Opinions on Adequacy of Consultation Time

Consultation time n (%)

Too long 8 8

Adequate 44 44

44

Neutral 8 8

Inadequate 22 22

Very short 18 18

Total 100 100

Source: Field data 2013

When respondents were asked if the health care providers who had attended them gave

them adequate explanations about their health problems, 89% of the respondents

interviewed agreed, while only 3% of respondents disagreed and 8% were neutral

(table 4.7).

Table 4.7: Respondents Given Adequate Explanations of their Health

Problems

Adequate explanations n (%)

Agreed 89 89

Neutral 8 8

Disagreed 3 3

Total 100 100

Source: Field data 2013

Table4.8 showed that 68% of respondents said that they were given counseling about

their health problems, while 15% reported to have been not given counseling on their

health problems and 17% could not differentiate between explanation and counseling.

Table 4.8: Respondents Reported to Have Been Counseled

Respondents Counseled n (%)

Agreed 68 68

Neutral 17 17

Disagreed 15 15

45

Total 100 100

Source: Field data 2013

The majority of respondents (82%) responded that they were given adequate

instructions on how to use drugs they were prescribed for them, while 9% reported to

have not been given instructions and 9% were neutral (table 4.9).

Table 4.9: Respondents Given Instructions on How to Use Prescribed

Medicines

Instructions given n (%)

Agreed 82 82

Neutral 9 9

Disagreed 9 9

Total 100 100

Source: Field data 2013

Results showed that, 71% of the respondents interviewed reported that they were

physically examined at the health facilities they attended, 8% responded negatively on

the maintenance of privacy and 21% were neutral. When they were asked to give

reasons for lack of privacy they responded that the consultation rooms were shared by

two clinicians (table 4.10).

Table 4.10: Respondents Examined Physically and Privacy Maintained

Physically examined n (%)

Agreed 71 71

Neutral 21 21

Disagreed 8 8

Total 100 100

Source: Field data 2013

Among respondents interviewed, 46% perceived the physical state of the buildings at

the health facility they had attended as being satisfactory, 19% perceived as being very

good while 11% perceived as being poor and 24% were neutral (table4.11).

46

Table 4.11: Respondents’ Perception on Physical State of the Buildings

State of buildings n (%)

Very good 19 19

Satisfactory 46 46

Neutral 24 24

Poor 11 11

Total 100 100

Source: Field data 2013

Table 4.12 showed that 25% of the respondents interviewed perceived the total waiting

time they had spent to get health care services to be too long, while 56% of them

perceived it as being adequate. However, 19% of the respondents interviewed

perceived the total waiting time they had spent to get health care services as being

inadequate.

Table 4.12: Respondents’ Perception on Total Time to Get Health Care

Services

Respondents’ perception n (%)

Too long 25 25

Adequate 56 56

Inadequate 19 19

Total 100 100

Source: Field data 2013

Table 4.13 shows that a high proportion of respondents (87%) reported that they were

satisfied with the quality of health care services provided at the health facilities they

had attended. Among those who were satisfied, 11% perceived the quality of health

care services to be very good, 34% perceived to be good and 42% to be satisfactory.

Table 4.13: Respondents’ Satisfaction with the Quality of Health Care Services

Satisfaction status n (%)

Very good 11 11

Good 34 34

Satisfactory 42 42

47

Poor 13 13

Total 100 100

Source: Field data 2013

Respondents who perceived that the quality of health care services that they had

received as being satisfactory or very satisfactory were asked to explain. Table 4.14

shows that the reasons were good attitude of health providers (65%), well trained

health providers (71%), clean hospital surroundings (80%) and adequate explanations

of their health problems (89%). It should be noted that every factor was judged

independently.

Table 4.14: Respondents’ Reasons for Satisfaction with Quality of Health

Services

Reason for satisfaction n (%)

Good attitude of health providers 65 65

Well trained health providers 71 71

Adequate explanations of health problems 89 89

Clean hospital surroundings 80 80

Received all prescribed medicines 48 48

Source: Field data 2013

A total of 60% were not satisfied with the quality of health care services that they had

received. When they were asked to give the reasons for their dissatisfaction, the main

reasons were long waiting time (25%), failure to get all the prescribed medicines (26%)

and bad attitude of health providers (9%). However, apart from those reasons, other

reasons were poor trained health providers, lack of enough privacy and not clean

hospital surroundings (table 4.15). It should be noted that every factor was judged

independently.

Table 4.15: Respondents’ Reasons for Dissatisfaction with the Quality of

Services

Reasons for dissatisfaction n (%)

Long waiting time 25 25

48

Failure to get all prescribed medicines 26 26

Bad attitude of health care providers 9 9

Poor trained health care providers 8 8

Health facilities surroundings not clean 20 20

Lack of enough privacy 21 21

Source: Field data 2013

Respondents were interviewed to give their recommendations on what should be done

in order to improve the quality of health care services delivered in Kinondoni

municipal health facilities (table 4.16). Their recommendations were to improve the

availability of medicines and medical supplies (62%), followed by increasing the

number of health care providers (29%), well trained health care providers (24%),

health providers attitude toward patients should be improved (17%) and physical states

of building should be improved (14%).

Table 4.16: Respondents’ Recommendations on Improving the Health Services

Recommendations n (%)

Availability of medicines and other medical supplies should be improved 62 62

Number of health care providers should be increased 29 29

Health care providers should be well trained 24 24

Physical state of buildings should be improved and increased 14 14

Attitude of health providers should be improved 17 17

Source: Field data 2013

4.3 Facility Checklist

4.3.1 Services Offered

The results of facility assessment showed that the five municipal health facilities

provided a good range of health care services. Only few services were not offered in

all five health facilities, these were isolation wards, sterile preparation services and

physiotherapy services (table 4.17).

49

Table 4.17: Various Services Provided in Municipal Health Facilities

Service Municipal Health Facility

M/nyamala Lugalo Sinza Magomeni Tandale

Operating theatre Available Available Available Unavailable Not available

Laboratory Available Available Available Available Available

Radiology Available Available Available Unavailable Unavailable

Blood bank Available Available Available Unavailable Unavailable

Dental unit Available Available Available Available Unavailable

Eye unit Available Available Available Available Unavailable

Physiotherapy Available Available Unavailable Unavailable Unavailable

Sterile unit Available Available Unavailable Unavailable Unavailable

Isolation ward Unavailable Unavailable Unavailable Unavailable Unavailable

Mortuary Available Available Available Unavailable Unavailable

Source: Field data 2013

4.3.2 State of Physical Structures

The buildings of Mwananyamala, Lugalo, Sinza and Tandale were in good physical

state with exception of Magomeni. The walls, ceiling boards, doors and windows were

found to be intact. It was noted that consultation rooms were not adequate in all

municipal health facility visited, as a result more than one clinicians shared one

consultation room except for specialist doctors. However, the rooms had adequate

space and well ventilated.

It was also noted that during physical examination visual privacy was maintained due

to presence of patient screens but audio privacy was difficult to maintain. In all five

health facilities, there were public toilets in the outpatient departments but they were

not clean and smelling. Some of them needed to be renovated.

4.3.3 Environmental Cleanliness

Overall cleanliness of the surroundings was good in all the five municipal health

facilities. There were neither long grasses nor piece of papers found scattered around

the facilities surroundings. All facilities had adequate solid and hazardous waste

50

materials collection and disposal facilities. Drainage systems were well functioning.

Also, all health facilities had adequate washing points near all service delivery and had

piped water and water storage tanks for ensuring constant flow of water.

CHAPTER FIVE

DISCUSSION OF THE FINDINGS

5.1 Introduction

This chapter presents the interpretation and discussion of the findings presented in

chapter four. Moreover, this chapter answers the questions on how and why the data

relate to the objectives of the study.

51

5.2 Provider – Client Interaction

Health service provider - client interactions include not only the attitudes of health

providers but also how the provider took trouble to make a proper diagnosis and

communicate information about the illness and management to the client.

Interpersonal relationship is an important factor for clients’ choice of the health facility

to get care. In a study done in Sri Lanka it was found that poor relationships between

public health providers and clients made clients to seek out health care services from

private health facilities, despite the fact that public health institutions had skilled and

technical competent health care providers (Russell, 2005). This study showed that 65%

of respondents were satisfied with the attitude of health providers in the five municipal

health facilities. However, a slight proportion of respondents (9%) perceived the

attitude of health providers to be poor.

Adequate consultation time is important in order to enable the provider to come up

with the correct diagnosis and appropriate management of the clients’ illness. In this

study, 44% of respondents interviewed perceived the consultation time they had spent

with the clinicians as being adequate. This study however, did not measure the actual

consultation time that respondents spent with their clinicians. Similarly, Msamanga et

al, (1996) in a study done in Mara and Kilimanjaro established an even higher

proportion (97.5%) of respondents who reported that the consultation time with health

care providers as being adequate.

Information exchange is also important during client – provider interactions. It

explains the flow of health information between the health care provider and the client.

Adequate information given to the client is very important for better compliance with

the treatment and hence improvement of quality of health services (Baker, 1990). In

this study, information exchange was assessed by asking the respondents in the

questionnaires whether they were given explanation about their health problems,

counseling, and advice on how to use the drugs prescribed to them and their side

effects.

52

Results showed that 89% of respondents interviewed agreed to have been given

adequate explanation about their health problems, while 68% agreed to have been

given counseling on their health problems and 82% agreed to have been given

adequate instructions on how to use drugs prescribed to them. However, the study did

not involve direct observation of the interaction between the health care provider and

the client but the study was limited to respondents’ perceptions on what they

experienced during their interactions with the health care providers. Similar findings

were reported by Mallya (2004) who established that 69% of the clients using user fee

interviewed reported to have been given adequate information about their health

problems.

The study findings also showed that 71% reported to have had physical examination

done. The issue of privacy during physical examination was also assessed as an

important part of provider – client interactions. The results showed that 21% reported

to have lacked privacy during physical examination. The possible explanation for this

was that two clinicians were sharing one consultation room.

5.3 Availability of Medicines and Medical Supplies

Availability of medicines, medical supplies and equipment is necessary for delivery of

health services. These items are important because they save lives, improve health of

the patients, promote trust of patients to the health delivery system and enhance

participation and ownership of the services. Most of deaths and causes of sufferings

and disabilities can be prevented, treated or alleviated with essential medicines,

medical supplies and equipment.

Availability of medicines and medical supplies in health facilities is one of the factors

that make patients to visit them for services. Some health facilities are preferred to

others due to this fact. The availability of drugs at the health facility is among the most

important components of the quality of primary health care services and therefore a

primary determinant of utilization of health care services (Msamanga et al, 1996). This

study showed that 55% of respondents interviewed reported that drugs were sometimes

53

available at the municipal health facilities they had attend, while a small proportion

(7%) reported that drugs were not available.

Similarly, studies done in other parts of the country have also established inadequate

drug availability to be problem. In a study done in Bagamoyo district, 63.6% of

patients interviewed reported that drugs were not available at all the time (Mallya,

2004). Another study done in Moshi rural district found that 92% of respondents in

public health units reported that drugs were available only in some days of the month

(Adam, 2001). However, this study did not study the cause of drug shortage in

Kinondoni municipal health facilities.

5.4 Waiting Time

Waiting time is that duration of time the patient spends waiting before receiving health

care services. Patients at health facilities often experience long queues. The problem

is largely attributed to the shortage of staff. On the other hand, some facilities serve a

very large population with limited equipment, shortage of drugs and other medical

supplies.

The results from this study showed that respondents spent long time in waiting to get

investigations done than waiting for other services (25%). They mentioned long queue

as the main reason for spending a lot of time. This was also confirmed during the

assessment of adequacy of rooms for various services using check list where it was

noted that there is only one laboratory and one radiology unit. These were being used

by all patients regardless of health financing option used, hence, delay in receiving

services occurred.

Long waiting time was also mentioned in the NHIF implementation report as one of

the factor causing dissatisfaction of clients with the quality of health care services

received under National Health Insurance Fund (NHIF, 2012).

54

5.5 Physical State of Buildings

Physical state of buildings was also assessed as an important aspect of health care

services delivery. About 65% of respondents interviewed perceived that physical state

of buildings in the municipal health facilities that they had attended to be satisfactory.

The main reason of satisfaction is likely to be due to the fact that the buildings of the

five municipal health facilities have been rehabilitated recently and in addition

renovation of some of the buildings was still going on while in some facilities (Lugalo

and Sinza) construction of new buildings were still going on as it was observed during

physical assessment of the physical state of the facilities buildings using a facility

checklist.

5.6 Patients’ Satisfaction or Dissatisfaction with Health Services Delivery

Patients’ satisfaction is regarded as one of the desired outcome of health care services

and is increasingly being used as a measure of the quality of care as it was stated by

Parasurman et al (1988) and Donabedian (1997). The results of this study showed that

87% of the respondents interviewed were satisfied with the quality of health care

services they had received.

When respondents were asked to give the reasons for their satisfaction with the quality

of services they had received, the majority mentioned good attitude of health care

providers (65%) and health providers are well trained. These were followed by

structural factors such as cleanliness of the health facility surroundings (80%) and

availability of drugs (48%). The findings of this study showed that providers’ attitude

towards clients is the most powerful determinant factor of client satisfaction with the

quality of health care services.

Although it is difficult for a client to judge health care providers’ technical skills due

to information asymmetry that exist between patients and providers, a higher

proportion of the interviewees reported great satisfaction with health care providers’

technical skills. This might be due to the fact that clients tend to have trust in the public

health facilities and in the technical competence of public health care providers as have

been established elsewhere (Russell, 2005). The findings of this study also conform to

the findings established by Msamanga et al (1996) which showed that perceived

55

providers’ technical competence and provider-patient interactions to be the main

factors which determined clients’ satisfaction with the quality of health care services.

In this study, structural elements of quality were mostly mentioned as dissatisfying

factors particularly poor availability of medicines and medical supplies (26%) and long

waiting time (25%), followed by lack of privacy (21%), bad attitude of health care

providers (9%) and poor trained health care providers (8%). The findings from the

studies done from other developing countries also showed that long waiting time is

associated with the highest level of dissatisfaction with quality of health care.

5.7 Contributions of Health Insurance towards Improvement of Health Services

The primary purpose of health insurance is to generate revenue. In public sectors fees

are usually introduced to supplement public funds when those sectors fail to keep up

with the cost of providing services to meet increasing demand. Although the primary

purpose is to generate revenue but the total amount of revenue generated is unlikely to

be sufficient to meet the growing need and demand for high quality health care services

(Newbrander and Sacca, 1996).

The introduction of health insurance in the government health facilities has been one

of the most visible policy changes associated with changes from government

dominated health services to market oriented health services financing provision.

Since government resources were decreased while demand have been increased in

many countries, more private resources have been needed to increase the quality and

quantity of health services (Newbrander and Sacca, 1996).

NHIF was viewed as a means of generating additional revenue in the health sector,

improving quality of health services as well as promoting equity, accessibility and

efficiency in the use of public health services in Tanzania (MOH, 1997). Many studies

have been done to assess the impact of health insurance on the quality of health care

services. In some countries evidence indicated that insurance improved quality of

health care and attendance in public health facilities, while in some areas insurances

are reported to have caused under utilization of health services.

56

Assessment of equity implication of health sector user in Tanzania found that there is

limited positive evidence that insurance have in general achieved their objectives of

sustainability, drug availability, quality care and access to the poor. In this study,

respondents perceived that insurance played a role towards improvement of health care

services. The study revealed that a higher proportion of respondents (87%) were

satisfied with the quality of health care services provided at the health facilities they

had attended. Among those who were satisfied, 11% perceived the quality of health

care to be very good, 34% perceived to be good and 42% perceived to be satisfactory.

5.8 Improving the Quality of Health Care Services

According to the 2009 – 2015 Health Sector Strategic Plan III, quality in health

services is working according to specific standards which aim at improving the health

status of individuals and communities, reducing suffering due to diseases and illness

and increasing client’s satisfaction. At the same time efficiency and effectiveness is

increased (MOHSW, 2008). However, the concept of service quality should be

approached from the customer’s perception which determines the level of service

quality and satisfaction. Therefore, the customer is the best judge of the quality of

service and not the service provider (Edvarsson, 1998).

Availability of medicines, at the health facility is usually perceived as the most

important measure in improving the quality of health care services in many

communities (Msamanga et al, 1996). In this study, availability of medicines was

reported to be a problem. More than half (55%) of respondents responded that

medicines were sometimes available at the health facilities they attended. A similar

situation was reported in Bagamoyo district where it was observed that 63.6% of

respondents interviewed, reported that despite the introduction of health insurance,

shortage of medicines was one of the main problem that affected quality of health

services (Mallya, 2004).

Another important measure in improving the quality of health care services as

perceived by respondents is physical condition of the facility buildings. However, the

57

organizational, aspects such as number of staffs, qualification of staff, administrative

and managerial procedures are also important. This is due to the fact that poor quality

of health care services can also be contributed by poor performance of health workers

due to lack of knowledge, inability to translate sufficient acquired through training into

appropriate attitude and performance, and low staff morale and motivation caused by

meager wages and poor working environment.

In this study, in order to improve the quality of health care services, respondents

interviewed suggested that availability of medicines, medical supplies and equipment

should be improved (62%), the number of staff should be increased (29%), staff should

be well trained (24%), attitude of health workers should be improved (17%), physical

state of buildings should be improved (14%) and time to get services should be

improved.

5.9 Market Failure

Market failure is a concept within economic theory where the allocation of goods and

services by a free market is not efficient. There is the problem which prevents the

market from operating efficiently. Market failure refers to a situation where the market

in theory is supposed to function but may fail to do so in practice. The prevalence of

market failure is due to lack of conviction in favor of markets, the inflexibility of

intervening government agencies and political forces that enable certain interest

groups to benefit at the expense of society as a whole (Winston, 2006).

In health care market, the illnesses and the diseases of the patients and their treatments

and investigations are the commodities that are traded. Thus illness and diseases and

their investigations and treatment have a market value. Kenneth (1963) identified that

health care is inherently subject to market failure. While the government might be able

to improve some of the institutional and organization deficiencies, it will not be able

to improve all market deficiencies since some of the problems facing the government

are similar to those facing the market (Stiglitz, 1989).

58

In this study, availability of drugs and medical supplies found to be a problem in all

five municipal health facilities. The study revealed that only 12% of respondents

interviewed reported that drugs were always available, 26% reported that drugs were

available, while 55% reported that drugs were sometimes available and 7% reported

that drugs were not available. A quarter of clients (25%) perceive waiting time to be

long.

5.10 Government Failure

Government fails when an intervention is unwarranted because markets are performing

well or when the intervention fails to correct a market problem efficiently (Winston,

2006). Government failure is the public sector analogy to market failure and occurs

when the government intervention causes more inefficient allocation of goods and

resources than would occur without the intervention. Some types of interventions such

as taxes, subsidies, price control and regulations including attempts to collect market

failure may also lead to an inefficient allocation of resources which may make the

matter worse rather than better.

In Tanzania the health care services were previously provided free of charge. The

government was the main provider of health services in the country and the sole source

of health financing. However, the problems of implementation of vertical programs,

inappropriate utilization of manpower, improperly financing referral system, shortage

of staff and inadequate medicines and medical supplies made the government to

change its role from that of provider to facilitator and adopt user fee as alternative

health financing mechanism (MOH, 1997).

This study showed that 26% of respondents were dissatisfied with the quality of health

delivered due to failure to get all the prescribed medicine, 25% due to long waiting

time, 21% due to lack of privacy and 17% due to bad attitude of and poor trained health

care providers.

59

CHAPTER SIX

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

6.1 Introduction

This chapter summarizes the findings of the study, presents conclusions and makes

recommendations.

6.2 Summary

A cross section study was conducted in Kinondoni municipal health facilities in April

to May 2013 with the main objective of assessing delivery of health care services as

perceived by civil servants using NHIF. A total of 100 respondents were interviewed.

60

Respondents were selected using convenience sampling method. A structured

questionnaire and facility check lists were used to collect data.

The study findings showed that health provider – patient interaction was perceived to

be satisfactory with 51% of respondents. Eighty nine percent of respondents reported

to be given adequate explanations of their health problems, while 82% reported to be

given adequate instructions on how to use prescribed medicine, 68% agreed to be

counseled and 71% reported to have been physically examined. The majority of

respondents (80%) were satisfied with the cleanliness of facility surroundings.

Respondents were also interviewed on the aspect of duration of time they spent waiting

to get services. A quarter of respondents interviewed (25%) perceived waiting time to

be too long, while 56% perceived to be adequate. Availability of drugs was reported

to be a problem in this study, more than half (55%) of respondents responded that

drugs were sometimes available at the facility they attended. The level of respondents

satisfaction with the quality of health care services was high (87%) with a small

proportion (13%) being dissatisfied mainly due to lack of privacy and failure to get all

prescribed medicines.

In order to improve the delivery of health care services respondents suggested that

availability of medicines, medical supplies and equipments should be improved. The

government should ensure that the health care providers are well trained and adequate.

Furthermore, the time spent to get services, physical state of buildings and attitude of

health care providers should be improved. The researcher recommended that

respondent’s opinions should be considered in strategic planning to improve delivery

of quality health care services.

6.3 Conclusion

The study revealed that respondents were satisfied with the health care services

delivered by the Kinondoni municipal health facilities. Respondents were satisfied

with the quality of health care services they had received in Kinondoni municipal

health facilities, particularly on consultation time, information sharing and patient –

61

provider interactions based on the attitude of health providers towards patients.

Respondents were also satisfied with physical states of facilities buildings and

cleanliness of the facilities surroundings.

Respondents perceived that health insurance played a great role towards the

improvement of health care services by improving the availability of medicines,

medical supplies and equipments to some extent. However, the study has also shown

that respondents perceived shortage of medicines, medical supplies and equipments as

a problem in all the municipal health facilities in Kinondoni. The study also revealed

that respondents’ perceived overall waiting time to be long (25%) and lack of privacy

due to shortage of consultation rooms.

In order to improve the delivery of health care services, respondents suggested that

availability of medicines, medical supplies and equipments should be improved. The

health care providers should be well trained and improved in number. The attitude of

health care providers, time spent to get services and physical state of buildings should

be improved.

6.4 Recommendations

In light of the above information and findings, the study came up with the following

recommendations on improving the delivery of health care services.

6.4.1 Specific Recommendations

(i.) Important measures should be taken to improve the availability of

medicines, medical supplies and equipments in the municipal health

facilities assessed.

(ii.) Respondent’s opinions on improving the quality of health care services

and their suggestions on how to improve the delivery of health care

services should be taken into consideration when planning strategies

targeted to improve the quality of health care services.

62

6.4.2 General Recommendations

(i.) The government through the Ministry of Health and Social Welfare

should identify the areas that need to be improved or restructured with

the aim of improving health and health delivery system by developing

and implementing efficient and effective plans.

(ii.) Before making plans and commitments for the introduction of social

insurance financing, the government should look more widely at the

exiting health care financing and provision arrangements. Insurance

should not be seen as a way of shifting core responsibilities for overall

regulation and policy making.

6.4.3 Areas for Further Researches

This study was conducted only in Kinondoni municipal, Dar es Salaam region. It is

hereby recommended that, the study be conducted in other municipal of Dar es Salaam

or other areas in Tanzania to confirm the findings. More research should be done

because the research has shown dissatisfaction in some areas in delivery of health care

services.

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APPENDICES

Appendix 1: The Informed Concert

Hallo, I am doing a study on Delivery of Health Care Services in Kinondoni Municipal

Health Facilities with a particular attention to Civil servants using NHIF. I am coming

from Mzumbe University. The information obtained from this study will help to

inform the policy makers and implementers about the quality of health care services

as perceived by users, and will help them to make appropriate changes so as to improve

quality of health care services in Kinondoni municipal health facilities.

All information obtained from this study will be confidential and will only be used for

the purpose of the study. It will not be disclosed or released to anyone except the

authorized person. Your participation is voluntary and will be highly appreciated. Your

name will not appear on the questionnaire therefore, nobody will be able to know from

whom the information has been obtained.

69

Do you agree to be interviewed? (Start interview if he/she responds positively, if

respond negatively thank him/her and approach another client).

70

Appendix 2: Client Questionnaire (English Version)

QUESTIONNAIRE NO ………………………………………….……………………

DATE……………………………………………………………………………..……

NAME OF THE INTERVIEWER……………………………………………..………

NAME OF THE HEALTH FACILITY…………………………………………..……

1. Sex: Male…………………… Female…………………(tick appropriate)

2. Age (in years)…………………………………………………………………

3. Marital status (circle the appropriate)

(i) Single

(ii) Married

(iii) Divorced

(iv) Widowed

4. Educational status

(i) Primary education

(ii) Secondary education

(iii) Post secondary education

(iv) Others (specify)………………………………………………………

5. Where do you live?..…………………...……………………………………

6. Which mode of transport did you use to come here?

(i) On foot

(ii) Public transport

(iii) Tax

(iv) Others (specify)………………………………………………………

71

7. What is the reason that made you to come to this health facility? (multiple

answers are allowed)

(i) Close to where I live

(ii) Directed by a friend/relative

(iii) A friend/relative works here

(iv) I was given a referral

(v) Good quality of health care services

8. How did you pay for the health care services that you have received today?

(i) Through NHIF

(ii) Through user fees

9. For how long have you been a member of NHIF? ........................................

10. What is the problem(s) that made you to come to this health facility?

(State)…………………………………………………………………………

11. On a scale of 1 – 5 upon arriving at the reception how were you received by

the health worker?

(i) Very politely

(ii) Politely

(iii) Neutral

(iv) Not politely

(v) Rude

12. On a scale of 1 – 5 how did the doctor receive you when you entered the

doctor’s room?

(i) Very politely

(ii) Politely

(iii) Neutral

(iv) Rude

(v) Very rude

72

13. On a scale of 1 – 5 did you feel comfortable when you were explaining your

problems to the doctor?

(i) Very comfortable

(ii) Comfortable

(iii) Neutral

(iv) Uncomfortable

(v) Very uncomfortable

14. On the scale of 1- 5, in your opinion how did you find the time the doctor spent

listening to you?

(i) Adequate

(ii) Inadequate

(iii) Too long

(iv) I don’t know

(v) Very short

15. Were you told what disease is affecting you?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

16. What type of health problem do you have?

(i) Acute

(ii) Chronic

73

17. On a scale of 1 – 5 did the doctor give you adequate explanations about your

health problem?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

18. On a scale of 1 – 5 were you given an opportunity to ask questions regarding

to your health problem?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

19. On the scale of 1 – 5 were you given counseling regarding to your health

problem?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

20. On the scale of 1 – 5 did the doctor examine you physically?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

74

21. Were you given explanation about the procedure before you were examined?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

22. How did you find the time the doctor spent in examining you?

(i) Adequate

(ii) Inadequate

(iii) Too long

23. Was the nurse present during physical examination?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

24. On the scale of 1 – 5 did the doctor recommend any investigations?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

25. On a scale of 1 – 5 if yes, were you able to get all investigations done?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

75

26. If no, what is the reason(s) why the investigations were not done? (multiple

answers are allowed)

(i) Non functioning equipment

(ii) Reagents out of stock

(iii) Technician was not present

(iv) The investigation was not done at the health facility

(v) Others (specify)………………………………………………………

27. Where you told how your disease would be managed?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

28. Were any medicines prescribed for you?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

29. If yes, did you get all the prescribe medicine?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

30. Is there any reason why you did not get all or some of the prescribed medicine?

76

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

31. Where you given enough instructions on how to use the prescribed medicine?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

32. Were you told the side effects of the medicines prescribed?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

33. In your opinion how do you find the availability of medicines in this health

facility?

(i) Always available

(ii) Available

(iii) Sometime available

(iv) Not available

34. Were you told next appointment?

(i) Strongly agree

77

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

35. Have you been to any other health facility to get treatment for the same

problem?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

36. Do you know how much you have paid for various services that you have

received?

(i) Registration…………………………………….………………………

(ii) Medicines………………………………………………………………

(iii) Investigations………………………………………………………..…

(iv) Others………………………………………………………………..…

37. On the scale of 1 – 5 in your opinion were the services that you have received

worth the money you paid?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

38. On a scale of 1 – 5 in your opinion how did you find the time you spent to get

services in various departments?

(i) Adequate

78

(ii) Inadequate

(iii) Reasonable

(iv) Too long

(v) Too short

39. On a scale of 1 – 5 how did you find the comfort ability of the waiting area?

(i) Very satisfactory

(ii) Satisfactory

(iii) Neutral

(iv) Poor

(v) Very poor

40. On a scale of 1 – 5 in your opinion how did you find the attitude of health

workers whom you came into contact with?

(i) Very satisfactory

(ii) Satisfactory

(iii) Neutral

(iv) Poor

(v) Very poor

41. Please give explanations of your answer………………………………………

42. On scale of 1 – 5 how did you find the cleanliness of the facility building?

(i) Very satisfactory

(ii) Satisfactory

(iii) Neutral

(iv) Poor

(v) Very poor

43. On a scale of 1 – 5 how did you find the cleanliness of the surroundings?

(i) Very satisfactory

(ii) Satisfactory

79

(iii) Not satisfactory

(iv) Poor

(v) Very poor

44. On the scale of 1 – 5 what can you say about physical state of the buildings?

(i) Very good

(ii) Satisfactory

(iii) Neutral

(iv) Poor

(v) Very poor

45. Please give explanation of your answer………………………………………

46. In your opinion how do you perceive about the quality of health care services

provided in this health facility?

(i) Very good

(ii) Good

(iii) Satisfactory

(iv) Poor

(v) Very poor

47. Are you satisfied with the quality of health services that you have received

today?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

48. In your opinion do health workers use good language?

(i) Strongly agree

(ii) Agree

80

(iii) Neutral

(iv) Disagree

(v) Strongly disagree

49. In your opinions are staffs well trained?

(i) Strongly agree

(ii) Agree

(iii) Neutral

(iv) Disagree

(v) Very disagree

50. In your opinions how can the quality of health care services in this health

facility improved?

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

81

Appendix 3: Clients Questionnaire (Swahili Version)

FOMU YA MASWALI

SWALI NAMBA……………………………………………………………………

TAREHE…………………………………………………………………………….

JINA LA MUULIZA MASWALI…………………………………………………..

1. Jinsia: Mwanaume…………………….Mwanamke…………………………

2. Umri (miaka)…………………………………………………………………

3. Hali ya ndoa (zungushia jibu sahihi)

(i.) Sijaoa/sijaolewa

(ii.) Nimeoa/nimeolewa

(iii.) Nimeachika

(iv.) Mjane

4. Kiwango cha elimu

(i.) Elimu ya msingi

(ii.) Elimu ya sekondari

(iii.) Zaidi ya elimu ya sekondari

(iv.) Elimu nyingine (eleza)

5. Unaishi wapi?.....................................................................................................

6. Umetumia usafiri gani kuja hapa?

(i.) Kwa miguu

(ii.) Kwa usafiri wa umma

(iii.) Kwa teksi

(iv.) Usafiri wa aina nyingine (eleza)

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7. Sababu iliyosababisha uje kupata matibabu hapa (jibu zaidi ya moja

linaruhusiwa)

(i.) Karibu na mahali ninapoishi

(ii.) Nimeelekezwa na rafiki/jamaa

(iii.) Nilipewa rufaa

(iv.) Huduma nzuri afya zinazotolewa

8. Umelipia gharama za matibabu uliyopata kwa njia gani?

(i.) Kwa kutumia bima ya afya

(ii.) Kwa kutumia malipo kwa mtumiaji

9. Umekuwa mwanachama wa mfuko wa bima ya afya kwa muda gani?

10. Tatizo gani limesababisha uje kupata matibabu hapa?

11. Katika skeli ya 1 – 5 ulipofika hospitali ulipokelewaje na mtoa huduma?

(i.) Kwa ukarimu sana

(ii.) Kwa ukarimu

(iii.) Kawaida

(iv.) Bila ukarimu

(v.) Kwa jeuri

12. Katika skeli ya 1 – 5 daktari alikupokeaje ulipoingia ofisini kwake ?

(i.) Kwa ukarimu sana

(ii.) Kwa ukarimu

(iii.) Kawaida

(iv.) Kwa jeuri

(v.) Kwa jeuri sana

83

13. Katika skeli ya 1 – 5 ulijisikiaje wakati unamweleza daktari matatizo yako?

(i.) Vizuri sana

(ii.) Vizuri

(iii.) Kawaida

(iv.) Vibaya

(v.) Vibaya sana

14. Katika skeli ya 1 – 5 kwa maoni yako unaoje muda aliotumia daktari kusikiliza

Matatizo yako ?

(i) Unatosha

(i.) Hautoshi

(ii.) Mrefu sana

(iii.) Sijui

(iv.) Mfupi sana

15. Uliambiwa unasumbuliwa na ugonjwa gani ?

(i.) Niliambiwa kabisa

(ii.) Niliambiwa

(iii.) Sina uhakika

(iv.) Sikuambiwa

(v.) Sikuambiwa kabisa

16. Una tatizo gani la kiafya?

(i.) La muda mfupi

(ii.) La muda mrefu

84

17. Katika skeli ya 1 – 5 daktari alikupa maelezo ya kutosha kuhusu matatizo yako

Ya kiafya?

(i.) Nakubaliana kabisa

(ii.) Nakubali

(iii.) Sina uhakika

(iv.) Sikubali

(v.) Sikubaliani kabisa

18. Katika skeli ya 1 – 5 ulipewa muda wa kuuliza maswali kuhusu matatizo yako

Ya kiafya ?

(i.) Nakubalina kabisa

(ii.) Nakubali

(iii.) Sina uhakika

(iv.) Sikubali

(v.) Sikubaliani kabisa

19. Katika skeli ya 1 – 5, ulipewa ushauri nasaha kuhusu matatizo yako ya kiafya?

(i.) Ndiyo, nilipewa

(ii.) Nilipewa

(iii.) Sina uhakika

(iv.) Sikupewa

(v.) Sikupewa kabisa

20. Katika skeli ya 1 – 5 daktari alikupima?

(i.) Ndiyo, alinipima

(ii.) Alinipima

(iii.) Sina uhakika

(iv.) Hakunipima

(v.) Hakunipima kabisa

21. Katika skeli ya 1 – 5, ulipewa maelezo kabla ya kupimwa ?

85

(i.) Ndiyo nilipewa

(ii.) Nilipewa

(iii.) Sina uhakika

(iv.) Sikupewa

(v.) Sikupewa kabisa

22. Unaonaje muda aliotumia daktari kukupima?

(i.) Unatosha

(ii.) Hautoshi

(iii.) Mrefu sana

23. Katika skeli ya 1 – 5, nesi alikuwepo wakati unapimwa?

(i.) Ndiyo, alikewepo

(ii.) Alikuwepo

(iii.) Sina uhakika

(iv.) Hakuwepo

(v.) Hakuwepo kabisa

24. Katika skeli ya 1 – 5, daktari alishauri ufanyiwe vipomo?

(i.) Ndiyo, alishauri

(ii.) Alishauri

(iii.) Sina uhakika

(iv.) Hakushauri

(v.) Hakushauri kabisa

25. Katika skeli ya 1 – 5, kama alishauri, ulipata vipomo vyote?

(i.) Ndiyo, nilipata

(ii.) Nilipata

(iii.) Sina uhakika

(iv.) Sikupata

(v.) Sikupata kabisa

26. Kama hukupata, kwanini hukupata (jibu zaidi ya moja linaruhusiwa)

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(i.) Vifaa vya kupimia vilikuwa havifanyi kazi

(ii.) Hakukuwa na kemikali za kupimia

(iii.) Hapakuwa na mtaalam wa kupima

(iv.) Kipimo hakikuwa kinafanyika hapo

(v.) Sababu zingine (eleza)

27. Katika skeli ya 1 – 5, uliambiwa jinsi ugonjwa wako utavyotibiwa?

(i.) Ndiyo, niliambiwa

(ii.) Niliambiwa

(iii.) Sina uhakika

(iv.) Sikuambiwa

(v.) Sikuambiwa kabisa

28. Katika skeli ya 1 – 5, uliandikiwa dawa?

(i.) Ndiyo niliandikiwa

(ii.) Niliandikiwa

(iii.) Sina uhakika

(iv.) Sikuandikiwa

(v.) Sikuandikiwa kabisa

29. Katika skeli ya 1 – 5, kama uliandikiwa, ulipata dawa zote?

(i.) Ndiyo, nilipata zote

(ii.) Nilipata

(iii.) Sina uhakika

(iv.) Sikupata

(v.) Sikupata kabisa

30. Katika skeli ya 1 – 5, kuna sababu iliyosababisha usipate dawa zote?

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(i.) Ndiyo, ipo

(ii.) Ipo

(iii.) Sina uhakika

(iv.) Hakuna

(v.) Hakuna kabisa

31. Katika skeli ya 1 – 5, ulipewa maelezo kuhusu utumiaji wa dawa?

(i.) Ndiyo nilipewa

(ii.) Nilipewa

(iii.) Sina uhakika

(iv.) Sikupewa

(v.) Sikupewa kabisa

32. Katika skeli ya 1 – 5, uliambiwa madhara ya hizo dawa?

(i.) Ndiyo, niliambiwa

(ii.) Niliambiwa

(iii.) Sina uhakika

(iv.) Sikuambiwa

(v.) Sikuambiwa kabisa

33. Kwa maoni yako unaonaje upatikanaji wa dawa katika hospitali hii?

(i.) Zinapatikana muda wote

(ii.) Zinapatikana

(iii.) Wakati mwingine zinapatikana

(iv.) Hazipatikani

34. Katika skeli ya 1 – 5, uliambiwa tarehe ya kurudi?

88

(i.) Ndiyo, niliambiwa

(ii.) Niliambiwa

(iii.) Sina uhakika

(iv.) Sikuambiwa

(v.) Sikuambiwa kabisa

35. Uliwahi kufika katika hospitali yoyote kupata matibabu kwa tatizo hili?

(i.) Ndiyo, niliwahi

(ii.) Niliwahi

(iii.) Sina uhakika

(iv.) Sijawahi

(v.) Sijawahi kabisa

36. Unajua gharama uliyolipia huduma mbalimbali za matibabu ulizopata?

(i.) Kujiandikisha…………………………………………………………..

(ii.) Dawa………………………………………………………….……….

(iii.) Vipimo…………………………………………………………………

(iv.) Huduma nyingine……………………………………………….……..

37. Katika skeli ya 1 – 5, huduma ulizopata zinalingana na gharama uliyolipa?

(i.) Ndiyo, zinalingana

(ii.) Zinalingana

(iii.) Sina uhakika

(iv.) Hazilingani

(v.) Hazilingani kabisa

38. Katika skeli ya 1 – 5, kwa maoni yako unaonaje muda uliotumia kupata

huduma Katika idara mbalimbali?

89

(i.) Unatosha

(ii.) Hautoshi

(iii.) Kawaida

(iv.) Mrefu sana

(v.) Mfupi sana

39. Katika skeli ya 1 – 5, unaonaje sehemu ya mapokezi?

(i.) Inaridhisha sana

(ii.) Inaridhisha

(iii.) Kawaida

(iv.) Hairidhishi

(v.) Hairidhishi kabisa

40. Katika skeli ya 1 – 5, kwa maoni yako unaonaje mwenendo wa watoa huduma?

(i.) Unaridhisha sana

(ii.) Unaridhisha

(iii.) Kawaida

(iv.) Mbaya

(v.) Mbaya sana

41. Tafadhali, toa maelezo ya jibu lako

…………………………………………………………………………………

42. Katika skeli ya 1 – 5, unaonaje usafi wa majengo ya hospitali hii?

(i.) Unaridhisha sana

(ii.) Unaridhisha

(iii.) Kawaida

(iv.) Hauridhishi

(v.) Hauridhishi kabisa

43. Katika skeli ya 1 – 5, unaonaje usafi wa mazingira ya hospitali hii?

(i.) Unaridhisha sana

(ii.) Unaridhisha

90

(iii.) Kawaida

(iv.) Hauridhishi

(v.) Hauridhishi kabisa

44. Katika skeli ya 1 – 5, unasemaje kuhusu hali ya majengo?

(i.) Nzuri sana

(ii.) Nzuri

(iii.) Inaridhisha

(iv.) Mbaya

(v.) Mbaya sana

45. Tafadhali, toa maelezo ya jibu lako

…………………………………………………………………………………

…………………………………………………………………………………

…………………………………………………………………………………

46. Kwa maoni yako unaonaje ubora wa huduma zitolewazo katika hospitali hii?

(i.) Nzuri sana

(ii.) Nzuri

(iii.) Zinaridhisha

(iv.) Mbaya

(v.) Mbaya sana

47. Katika skeli ya 1 – 5, umeridhika na ubora wa huduma ulizopata leo?

(i.) Nimeridhika sana

(ii.) Nimeridhika

(iii.) Kawaida

(iv.) Sijaridhika

(v.) Sijaridhika kabisa

48. Kwa maoni yako, watoa huduma wanatumia lugha nzuri?

(i.) Ndiyo, nakubali

(ii.) Nakubali

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(iii.) Kawaida

(iv.) Sikubali

(v.) Sikubali kabisa

49. Kwa maoni yako, watoa huduma ya afya wamepata mafunzo ya kutosha?

(i.) Nakubali kabisa

(ii.) Nakubali

(iii.) Kawaida

(iv.) Sikubali

(v.) Sikubali kabisa

50. Kwa maoni yako, kwa namna gani huduma za afya zinaweza kuboreshwa?

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Appendix 4: Facility Check List to Assess Health Services Delivered

CHECK LIST NO…………………………………………………………………….

92

NAME OF THE HEALTH FACILITY……………………………………………….

DATE………………………………………………………………………………….

NAME OF RESEARCHER……………………………………………………………

SERVICES OFFERED BY THE HEALTH FACILITY

SERVICE AVAILABLE UN AVAILABLE REMARKS

Dental unit

Eye unit

Blood bank

Laboratory

Radiology unit

Operating theatre

Sterile preparation unit

Physiotherapy unit

Isolation ward

Refrigerated mortuary