Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania: a cross-sectional study

BMC Health Services Research

Svetla Loukanova¹  Rainer Sauerborn¹  Hengjin Dong⁶  Pencho Tonchev⁷  Germain Savadogo⁴  Maxwell A Dalaba⁵  Siriel Massawe³  Els Duysburgh²  Happiness P Saronga³ 

[1]Department of Public Health, University of Heidelberg, Heidelberg, Germany

[2]International Center for Reproductive Health (ICRH), Ghent University, Ghent, Belgium

[3]Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania

[4]Centre de Recherche en Santé de Nouna (CRSN), Nouna, Burkina Faso

[5]Navrongo Health Research Center, Navrongo, Ghana

[6]Centre for Health Policy Studies, School of Public Health, Zhejiang University, Hangzhou, China

[7]Clinic of Surgery, University Hospital “Dr. G.Stranski”, Pleven 5800, Bulgaria

关键词: Health care provider;    Tanzania;    Rural area;    Efficiency;    Quality;    Unit cost;    Cost;    Childbirth;    Antenatal care;   

Others  :  1133994
DOI  :  10.1186/1472-6963-14-96

 received in 2013-05-13, accepted in 2014-02-18,  发布年份 2014

【 摘 要 】

Background

Cost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning.

Methods

This was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described.

Results

The health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency.

Conclusions

Differences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives.

【 授权许可】

   
2014 Saronga et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]WHO: World Health Statistics: A Snapshot of Global Health. Geneva, Switzerland: WHO Press; 2012. [http://apps.who.int/iris/bitstream/10665/70889/1/WHO_IER_HSI_12.1_eng.pdf webcite]
• [2]WHO: Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF, UNFPA and the World Bank Estimates. Geneva, Switzerland: WHO Press; 2012. [http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf?ua=1 webcite]
• [3]National Bureau of Statistics (NBS) [Tanzania], ICF Macro: Tanzania Demographic And Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro; 2011.
• [4]The World Bank Website [http://data.worldbank.org/indicator/SH.DYN.NMRT webcite]
• [5]The World Bank Website [http://data.worldbank.org/indicator/SP.DYN.IMRT.IN webcite]
• [6]URT: The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008–2015. Dar es salaam, Tanzania: Ministry of Health and Social Welfare; 2008. [http://www.unfpa.org/sowmy/resources/docs/library/R224_MOHTanzania_2008_Roadmap_MNCH.pdf webcite]
• [7]WHO: WHO Global Health Expenditure Atlas. Geneva, Switzerland: WHO Press; 2012. [http://www.who.int/nha/atlas.pdf webcite]
• [8]Both CV, Jahn A, Flessa S: Costing maternal health services in South Tanzania. A case study from Mtwara Urban District. Eur J Health Econ 2008, 9:103-115.
• [9]Berman P: Cost efficiency in primary health care: studies of health facilities in Indonesia. Health Policy Plan 1989, 4(4):316-322.
• [10]Aboagye A, Degboe A, Obuobi A: Estimating the cost of healthcare delivery in three hospitals in Southern Ghana. Ghana Med J 2010, 44(3):83-92.
• [11]Flessa S: The costs of hospital services: a case study of Evangelical Lutheran Church hospitals in Tanzania. Health Policy Plan 1998, 13(4):397-407.
• [12]Kowalenski M, Mujinja P, Jahn A: Can mothers afford maternal health care costs? User costs of maternity services in rural Tanzania. Afr J Reprod Health 2002, 6(1):65-73.
• [13]Marshall P, Flessa S: Efficiency of primary care in rural Burkina Faso. A two-stage DEA analysis. Heal Econ Rev 2011, 1:5. doi:10.1186/2191-1991-1-5 BioMed Central Full Text
• [14]Mugisha F, Kouyate B, Dong H, Sauerborn R: Costing health care interventions at primary health facilities in Nouna, Burkina Faso. Afr J Health Sci 2002, 9:1-2.
• [15]Mills A, Kapalamula J, Chisimbi S: The Cost of the district hospital: a case study in Malawi. Bull World Health Organ 1993, 71(3/4):329-339.
• [16]Levin A, Dmytraczenko T, McEuen M, Ssengooba F, Mangani R, Van Dyck G: Costs of maternal health care services in three Anglophone African countries. Int J Health Plann Manag 2003, 18(1):3-22.
• [17]Levin A, Mangani R, McEuen M, Chaweza R, Chizani N: Cost Of Maternal Health Care Services In Blantyre District Malawi. Special Initiatives Report 17. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc.; 1999.
• [18]Levin A, Dmytraczenko T, McEuen M, Ssengooba F, Mirembe F, Okui O, Nakakeeto , Cowley P: Costs Of Maternal Health Care Services in Masaka District Uganda. Special Initiative Report 16. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc.; 1999.
• [19]Akazili J, Adjuik M, Chatio S, Kanyomse D, Hodgson A, Aikins M, Gyapong J: What are the technical and allocative efficiencies of public health centers in Ghana? Ghana Med J 2008, 42:149-155.
• [20]The United Republic of Tanzania National Website [http://www.lindi.go.tz/lindi_rural.html webcite]
• [21]URT: National Census Lindi Regional And District Projections. Dar es salaam: National Bureau Statistics and Ministry of Planning, Economy and Empowerment; 2006.
• [22]URT: Health Sector Performance Profile Report 2010 Update. Dar es salaam, Tanzania: Ministry of Health and Social Welfare; 2010.
• [23]URT: National Census Mtwara Regional And District Projections. Dar es salaam: National Bureau Statistics and Ministry of Planning, Economy and Empowerment; 2006.
• [24]The QUALMAT project Website [http://www.qualmat.net webcite]
• [25]Conteh L, Walker D: Cost and unit cost calculations using step-down accounting. Health Policy Plan 2004, 19(2):127-135.
• [26]Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL: Methods for the Economic Evaluation of Health Care Programmes. 3rd edition. Oxford: Oxford University Press; 2005.
• [27]Flessa S, Moeller M, Ensor T, Hornetz K: Basing care reforms on evidence: the Kenya health sector costing model. BMC Health Serv Res 2011, 11:128. BioMed Central Full Text
• [28]WHO: Integrated Management Of Pregnancy And Childbirth. WHO Recommended Interventions For Improving Maternal And Newborn Health. Geneva, Switzerland: WHO Press; 2009. [http://whqlibdoc.who.int/hq/2007/who_mps_07.05_eng.pdf webcite]
• [29]Duysburgh E, Zhang WH, Ye M, Williams A, Massawe S, Sié A, Williams J, Mpembeni R, Loukanova S, Temmerman M: Quality of antenatal and childbirth care in selected rural health facilities in Burkina Faso, Ghana and Tanzania: similar finding. Trop Med Int Health 2013. doi:10.1111/tmi.12076
• [30]URT: The 11th Joint Annual Health Sector Review Tanzania. Dar es salaam, Tanzania: Ministry of Health and Social Welfare; 2010.
• [31]Gross K, Alba S, Glass TR, Schellenberg JA, Obrist B: Timing of antenatal care for adolescent and adult pregnant women in South-eastern Tanzania. BMC Pregnancy Childbirth 2012, 12:16. BioMed Central Full Text
• [32]Mpembeni RNM, Killewo JZ, Leshabari MT, Massawe SN, Jahn A, Mushi D, Mwakipa H: Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: implications for achievement of MDG-5 targets. BMC Pregnancy Childbirth 2007, 7:29. BioMed Central Full Text
• [33]Mrisho M, Obrist B, Schellenberg JA, Haws RA, Mushi AK, Mshinda H, Tanner M, Schellenberg D: The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy Childbirth 2009, 9:10. BioMed Central Full Text
• [34]Kruk ME, Mbaruku G, McCord CW, Moran M, Rockers PC, Galea S: Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania. Health Policy Plan 2009, 24:279-288.
• [35]Magoma M, Requejo J, Campbell OMR, Cousens S, Filippi V: High ANC coverage and low skilled attendance in a rural Tanzanian district: a case for implementing a birth plan intervention. BMC Pregnancy Childbirth 2010, 10:13. BioMed Central Full Text
• [36]Kruk ME, Mbaruku G, Rockers PC, Galea S: User fee exemptions are not enough: out-of-pocket payments for ‘free’ delivery services in rural Tanzania. Trop Med Int Health 2008, 13(12):1-10.
• [37]Mrisho M, Schellenberg JA, Mushi AK, Obrist B, Mshinda H, Tannar M, Schellenberg D: Factors affecting home delivery in rural Tanzania. Trop Med Int Health 2007, 12(7):862-872.
• [38]Pembe AB, Urassa DP, Darj E, Carlstedt A, Olsson P: Qualitative study on maternal referrals in rural Tanzania: decision making and acceptance of referral advice. Afr J Reprod Health 2008, 12(2):120-131.
• [39]Kowalenski M, Jahn A, Kimatta SS: Why do at-risk mothers fail to reach referral level? Barriers beyond distance and cost. Afr J Reprod Health 2000, 4(1):100-109.
• [40]Gabrysch S, Campbell OMR: Still too far to walk: literature review of the determinants of delivery service use. BMC Pregnancy Childbirth 2009, 9:34. BioMed Central Full Text
• [41]Prata N, Greig F, Walsh J, West A: Ability to pay for maternal health services: what will it take to meet WHO standards. Health Policy 2004, 70:163-174.
• [42]Borghi J, Storeng KT, Veronique F: Overview of the costs of obstetric care and the economic and social consequences for households. Health Serv Organ Pol 2008, 24:23-46.
• [43]Perkins M, Brazier E, Themmen E, Bassane B, Diallo D, Mutunga A, Mwakajonga T, Ngobola O: Out of pocket costs for facility based maternity care in three African countries. Health Policy Plan 2009, 24:289-300.
• [44]Spangler SA, Bloom SS: Use of biomedical obstetric care in rural Tanzania. The role of social and material inequalities. Soc Sci Med 2010, 71:760-768.
• [45]Manzi F, Schellenberg JA, Hutton G, Wyss K, Mbuya C, Shirima K, Mshinda H, Tanner M, Schellenberg D: Human resources for health care delivery in Tanzania: a multifaceted problem. Hum Resour Health 2012, 10:3. BioMed Central Full Text
• [46]Borghi J: What is the cost of maternal health care and how can it be financed? In Safe Motherhood Strategies: A Review of the Evidence. 17th edition. Edited by De Brouwere V, Van Lerberghe W. Belgium: ITG Press; 2001:247-296. [Stud HealthServ Organ Policy]
• [47]Adam T, Ebener S, Johns B, Evans DB: Capacity utilization and the cost of primary care visits: implications for the costs of scaling up health interventions. Cost Eff Resour Alloc 2008, 6:22. BioMed Central Full Text
• [48]Levin A, Amin A, Rahman A, Saifi R, Khuda B, Mozumder K: Cost-effectiveness of family planning and maternal health service delivery strategies in rural Bangladesh. Int J Health Plann Manag 1999, 14:219-233.
• [49]Mushy D, Mpembeni R, John A: Effectiveness of community based safe motherhood promoters in improving the utilization of obstetric care. The case of Mtwara Rural District in Tanzania. BMC Pregnancy Childbirth 2010, 10:14. BioMed Central Full Text