Effectiveness of Health Sector Reforms in Reducing Disparities in Utilization of Skilled Birth Attendants in Tanzania

Abstract

Improving maternal health is a Millennium Development Goal adopted at the 2000 Millennium Summit of the United Nations. As part of the improving maternal health in Tanzania, it has been recommended that skilled birth attendants be present at all births to help reduce the high maternal mortality ratio. However, utilization of these attendants varies across socio-economic groups. The government of Tanzania has repeatedly attempted to carry out health sector reforms (HSRs) to alleviate disparities in health service utilization. In particular, around 1999, HSRs were incorporated into two approaches, including Decentralization by Devolution and Sector Wide Approach. This study aims to clarify the unresolved questions with little published evidence on the effect of HSRs on reducing disparities in utilization of skilled birth attendants across socio-economic groups over time. We used four cross-sectional datasets from the Tanzania Demographic and Health Survey: 1992Survey: , 1996Survey: , 1999Survey: , and 2004. Subjects included 14,752 women of reproductive age (15-49 years) and data on the most recent birth in the 5 years before each survey. Logistic regression analysis was performed with the dependent variable of whether respondents utilized skilled birth attendants or not, and with the main independent variables of time and socio-economic group. Results showed that the disparity in utilization of skilled birth attendants was significantly decreased from 1999 to 2004/05. These findings suggest that the two strategies, Decentralization by Devolution and Sector Wide Approach, in the process of HSRs are effective in reducing the disparities in utilization of skilled birth attendants among socio-economic groups.

Where There Is No Toilet: Water and Sanitation Environments of Domestic and Facility Births in Tanzania

“…Tanzania has seen a modest increase in the proportion of births occurring in health facilities; from 43.5% in 1999 to 50.1% in 2010 [7], but wide socio-economic inequalities in the utilization of skilled birth attendance exist [11]. To reduce maternal mortality, the Tanzanian government proposed scaling-up the availability of basic emergency obstetric and newborn care services at dispensaries and health centres, and improving the ability of rural health centres to perform caesarean sections and blood transfusions [6].…”

Does Decentralization Improve Health System Performance and Outcomes in Low‐ and Middle‐Income Countries? A Systematic Review of Evidence From Quantitative Studies

“…Table reports the characteristics of the articles selected for review. Sixteen different studies were identified, with the earliest one published in 2003 and the most recent one published in 2016 . The selected studies were situated in Latin America ( n = 8), Asia ( n = 5), Africa ( n = 2), and multiple countries ( n = 1).…”

“…The studies used cross‐sectional analysis ( n = 3) or longitudinal analysis ( n = 13); of the latter, 11 were based on panel data and 2 were based on repeated cross‐sectional. Among all studies, only 4 employed individual‐level analysis using individual or household data from survey data, whereas the remaining studies used the ecological analysis approach. The analytical methods that were used in the studies varied from fixed effects, modified difference‐in‐difference, instrumental variable estimation, multilevel modeling, and regression‐based analyses.…”

“…In terms of the effects of decentralization on health system inputs, 2 of the 3 studies showed adverse effects of decentralization, and 1 study did not find significant effects of decentralization on corruption . The impact of decentralization on health system performance was investigated in 7 studies and showed mixed findings . Two studies showed beneficial effects, 3 studies showed mixed results, 1 study showed harmful effects, and 1 study showed no significant effects …”

“…This may be attributed to variations among studies in outcome variables, decentralization constructs, and study designs used. In terms of outcome variables, measures of health system performance varied across studies and included the change in the population of low‐income individuals covered by public health insurance, delivery in health facilities, utilization of skilled birth attendants, coverage rates of immunization and complete immunization status among children, utilization of preventive and outpatient services, and out‐of‐pocket health expenditures . The decentralization variables used in these studies also reflect the different ways in which decentralization reforms are conceptualized: from the degree of control over fiscal resources and the degree of control by higher levels of government, to the timing of decentralization, to the adoption of a decentralization framework and the degree of mobilized health resources …”