User fees at point of service can represent a major barrier to access formal healthcare for low-income households, including maternal and childcare services. This problem is exacerbated when the quality of healthcare is perceived as low by potential patients. To increase access to formal care and reduce maternal mortality, Tanzania has since long exempted maternal and child health services from user fees across all government health facilities. Yet, many women still incur in direct and indirect fees when deciding to give birth in a government health facility in Tanzania. There are many potentially valid reasons for these generally undue payments, including special medicine prescriptions or treatments and transportation. Most government health facilities in Tanzania rely on locally generated fees to fund needs beyond staff salaries, for example some capital investments. These characteristics of healthcare financing generate incentives to extract informal payments for services officially offered free of charge. Governance is often mentioned as a ‘blockbuster’ tool to boost quality of care and curb corruption or more broadly reduce misconduct among public healthcare providers, including informal payments. However, whether facility-level governance levers can reduce user fees for exempted services in Tanzania remains a mostly unanswered empirical question.
My work aims to start filling this gap, studying the association between the likelihood of user fees for delivery in government health facilities and their monitoring arrangements (internally and involving the community), as well as the presence of quality management systems. The study builds on two large representative surveys administered by the DHS program: the 2014/2015 Service Provision Assessment survey and the 2015-16 Tanzania Demographic and Health Survey and Malaria Indicator Survey. I use georeferenced data for facilities and households clusters to match women who gave birth in government health facilities with the closest relevant health facility, focusing on the majority of cases where matching is unambiguous (i.e. there’s only one plausible matched facility). I then use a range of multilevel models and sets of covariates at the level of households and health facilities to measure the association between governance indicators and likelihood of user fees. To reduce concerns about potential endogeneity due to unobserved characteristics affecting simultaneously the outcome and the variables of interest, I also propose an instrumental variables approach building on the road distance between the matched health facility and the relevant District Medical Officer headquarter, which coordinate drug supply-chains and supervision of all health facilities within the local government authority.
Preliminary results suggest that having frequent meetings with the community and a functioning quality management system in place are significantly associated with a lower probability of paying user fees for delivery at government facilities. If confirmed, these results would be consistent with a positive role of social accountability initiatives, which push healthcare providers towards higher effort through increased social pressure from their constituencies.