REPOA is undertaking research funded by the Wellcome Trust to investigate -How do the payments that women make for maternal health care influence their experience during pregnancy and birth?. The project is led by Dr Paula Tibandebage of REPOA, with research collaborators from the Open University, UK, the Economic and Social Research Foundation (ESRF), Dar es Salaam, and the National Institute for Medical Research (NIMR), Dar es Salaam. Initial findings of the project shows that, while care during pregnancy and birth is officially free in the public sector, most women had made payments. Payments at birth were high relative to local incomes: an average of Tshs 12800 (USD 8) in the public sector and Tshs 29,500 (USD 18.5) in the faith-based facilities. Some of the project findings were presented on 11 December 2012at a findings sharing workshop. Participants included health researchers, medical and nursing practitioners and academics and policy practitioners.
The research was undertaken in four districts in two regions of Tanzania. Interviewees included 248 women who had given birth within the last five years, and also those in charge of maternity services and working midwives in 59 health facilities in public, faith-based and private facilities.
Initial findings of the project show that, while care during pregnancy and birth is officially free in the public sector, most women had made payments, including for antenatal care (ANC). In one rural district, women had paid an average of Tshs2300 (USD 1.4) for ANC but severe supply shortages meant that many women went without basic tests and treatments. In a second rural district, supplies were better but women paid much more for access, at facilities or in private shops an average of Tshs 3500or USD 2.2. Payments at birth were higher: an average of Tshs 12,800(USD 8 ) in the public sector and Tshs 29500 (USD 18.5) in the faith-based facilities. Discussion noted that research done fifteen years earlier similarly found substantial payments.
In urban public hospitals, staff shortages created severe stress on staff, and erratic demands for informal payments on the wards were associated with abusive behaviour. Yet some women had experienced free and competent care. In two urban public health centres, payments for care had become routinized and expected by both staff and women giving birth, and reported incidents of abusive behaviour were fewer. Discussion included the role of insurance as contributing to escalation of payment or conversely as a potential solution.
Interviews with maternity staff identified high levels of stress and frustration when supplies or staff shortages, over-work, poor working conditions lack of incentives, and lack of technical and moral support undermined good practice. One presentation identified empowerment of nurse/midwives to work effectively, including staff support and communication across hierarchy levels, as an essential ingredient of good care, and workshop discussion supported this argument, noting the important of teamwork. Another paper summarised the views of maternity staff and women interviewed on the nature of ethical care. A majority of women’s responses focused on avoidance of abuse and humiliation, while many staff responses also recognised this issue. Associated ethical issues included dignity, privacy and good communication. Replies also identified staff competence and available supplies as ethical matters concerning the health system as a whole. The workshop ended by discussing the extent to which some unethical vicious circles have become established between supply shortages, payments practices and abusive behaviour. Understanding how these interactions work is an important step in developing policies to tackle them.