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BackgroundHealth service data from Health Management Information Systems is important for decision-making at all health system levels. Data quality issues in low-and-middle-income countries hamper data use however.Smart Paper Technology, a novel digital-hybrid technology, was designed to overcome quality challenges through automated digitization. Here we assessed the impact of the novel system on data quality dimensions, metrics and indicators as proposed by the World Health Organization’sData Quality Review Toolkit.MethodsThis cross-sectional study was conducted between November 2019 and October 2020 in 13 health facilities sampled from 33 facilities of one district in rural Tanzania, where we implementedSmart Paper Technology. We assessed the technology’s data quality for maternal health care against the standardDistrict Health Information System-2applied in Tanzania.ResultsSmart Paper Technologyperformed slightly better than theDistrict Health Information System-2regardingconsistency between related indicatorsandoutliers. We found Smart Paper Technologywas inferior toDistrict Health Information System-2data in terms ofcompleteness. We observed that data on 1stantenatal care visitswere complete ⍰ 90% in only 76% of facilities for the new system against 92% for the standard system. For the indicatorinternal consistency over time73%, 59% and 45% of client numbers for antenatal, labour and postnatal care recorded in the standard system were documented in the new system.Smart Paper Technologyforms were submitted in 83% of the months for all service areas.ConclusionOur results suggest that not all client encounters were documented inSmart Paper Technology, affecting data completeness and partly consistency. The novel system was unable to leverage opportunities from automated processes because primary documentation was poor. Low buy-in of policymakers and lack of internal quality assurance may have affected data quality of the new system. We emphasize the importance of including policymakers in evaluation planning to co-design a data quality monitoring system and to agree on a realistic way to ensure reporting of routine health data to national level.

Background In April 2018, Tanzania introduced the human papillomavirus (HPV) vaccine nationally to 14-year-old girls, utilizing routine delivery strategies (i.e. vaccinating girls at health facilities and community outreach, including schools). We sought to assess awareness, feasibility, and acceptability of the HPV vaccination program among health workers and community-level stakeholders. Methods We conducted cross-sectional in-person surveys among health workers, school personnel, community leaders, and council leaders in 18 council areas across six regions of Tanzania in October–November 2019. Regions were purposively selected to provide demographic, geographic, and vaccination coverage variability; sub-regional levels used random or stratified random sampling. Surveys included questions on HPV vaccine training and knowledge, delivery strategy, target population, and vaccine and program acceptability. Descriptive analysis was completed for all variables stratified by respondent groups. Results Across the 18 councils, there were 461 respondents, including health workers (165), school personnel (135), community leaders (143), and council leaders (18). Over half of each respondent group (50–78%) attended a training or orientation on HPV vaccine. Almost 75% of the health workers and school personnel respondent groups, and less than half (45%) of community leaders correctly identified the target age group for HPV vaccine. Most (80%) of the health workers indicated HPV vaccination was available at health facilities and schools; most (79%) indicated that the majority of girls receive HPV vaccine in school. Approximately half (52%) of all respondents reported hearing misinformation about HPV vaccine, but 97% of all respondents indicated that HPV vaccine was either “very accepted” or “somewhat accepted” in their community. Conclusion The HPV vaccination program in Tanzania was well accepted by community stakeholders in 18 councils; adequate knowledge of HPV vaccine and the HPV vaccination program was demonstrated by health workers and school personnel. However, continued technical support for integration of HPV vaccination as a routine immunization activity and reinforcement of basic knowledge about HPV vaccine in specific community groups is needed. The Tanzania experience provides an example of how this vaccine can be integrated into routine immunization delivery strategies and can be a useful resource for countries planning to introduce HPV vaccine as well as informing global partners on how to best support to countries in operationalizing their HPV vaccine introduction plans.

Samwel Marco Tukay,1– 3 Liliane Pasape,1 Kassimu Tani,3 Fatuma Manzi3 1The Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania; 2Pangani District Council, Tanga, Tanzania; 3Ifakara Health Institute (IHI), Dar es Salaam, TanzaniaCorrespondence: Samwel Marco Tukay Email tukays@nm-aist.ac.tzBackground: Maternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania.Methods: This study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation.Results: Direct disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders’ engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor.Conclusion: Overall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.Keywords: health financing, direct health facility financing, health governing committee, maternal health, quality of care, Tanzania

Fever and malaria are highly prevalent among children under five across sub-Saharan Africa, but utilization and quality of care for febrile illness remain insufficient. Many studies examine socioeconomic and demographic determinants of care seeking; however, few assess how women's empowerment influences care seeking and quality. We examine associations of women's empowerment with: a) care utilization for children with fever and malaria and b) the quality of that care in 16 sub-Saharan African countries.This cross-sectional study used data from Demographic and Health Surveys conducted between 2010 and 2018. We constructed indices for economic, educational, sociocultural, and health-related empowerment and calculated the proportion of children with fever and malaria who sought care and received a range of recommended clinical actions. We used multivariable Poisson hurdle models to assess associations between empowerment, utilization, and number of components of quality care, controlling for socioeconomic and demographic factors.Our sample consisted of 25 871 febrile children, 4731 of whom had malaria diagnosed by rapid diagnostic test. Empowerment among mothers of children with fever was 0.50 (interquartile range, 0.38-0.63). In both the fever and malaria groups, over 30% of children were not taken for care. Among care seekers, febrile children received on average 0.47 (SD = 0.37) of components of quality care, and children with malaria received 0.38 (SD = 0.34). Multidimensional women's empowerment was significantly associated with care seeking and quality among febrile children, and with quality among children with malaria. Associations persisted after adjustment for socioeconomic and demographic characteristics.Results demonstrate substantial gaps in women's empowerment and poor utilization and quality of care for fever and malaria among children. Increased women's empowerment is associated with seeking care and, separately, obtaining high-quality care. To improve health outcomes, consideration of how empowering women can promote care seeking and extract quality from the health system is warranted.

Highlights: • Delivery costs represent 33% of total immunization program costs in Tanzania. • Costs are higher for outreach than for facility-based delivery. • We used calibration methods to estimate unit and total costs. • This work will inform domestic resource advocacy and planning., Introduction Information on the costs of routine immunization programs is needed for budgeting, planning, and domestic resource mobilization. This information is particularly important for countries such as Tanzania that are preparing to transition out of support from Gavi, the Vaccine Alliance. This study aimed to estimate the total and unit costs for of child immunization in Tanzania from July 2016 to June 2017 and make this evidence available to key stakeholders. Methods We used an ingredients-based approach to collect routine immunization cost data from the facility, district, regional, and national levels. We collected data on the cost of vaccines as well as non-vaccine delivery costs. We estimated total and unit costs from a provider perspective for each level and overall, and examined how costs varied by delivery strategy, geographic area, and facility-level service delivery volume. An evidence-to-policy plan identified key opportunities and stakeholders to target to facilitate the use of results. Results The total annual economic cost of the immunization program, inclusive of vaccines, was estimated to be US$138 million (95% CI: 133, 144), or $4.32 ($3.72, $4.98) per dose. The delivery costs made up $45 million (38, 52), or $1.38 (1.06, 1.70) per dose. The costs of facility-based delivery were similar in urban and rural areas, but the costs of outreach delivery were higher in rural areas than in urban areas. The facility-level delivery cost per dose decreased with the facility service delivery volume. Discussion We estimated the costs of the routine immunization program in Tanzania, where no immunization costing study had been conducted for five years. These estimates can inform the program’s budgeting and planning as Tanzania prepares to transition out of Gavi support. Next steps for evidence-to-policy translation have been identified, including technical support requirements for policy advocacy and planning.

BackgroundHealth information systems are important for health planning and monitoring of progress. Still, data from health facilities are often of limited quality in Low-and-Middle-Income Countries. Quality deficits are partially rooted in the fact that paper-based documentation is still the norm at facility level, leading to mistakes in summarizing and manual copying. Digitalization of data at facility level would allow automatization of these procedural steps. Here we aimed to evaluate the feasibility, usability and acceptability of a scanning innovation called Smart Paper Technology for digital data processing.MethodsWe used a mixed-methods design to understand users’ engagement with Smart Paper Technology and to identify potential positive and negative effects of this innovation in three health facilities in Southern Tanzania. Eight focus group discussions and 11 in-depth interviews with users were conducted. We quantified time used by health care providers for documentation and patient care using time-motion methods. Thematic analysis was used to analyze qualitative data. Descriptive statistics and multivariable linear models were generated to compare the difference before and after introduction and adjust for confounders.ResultsHealth care providers and health care managers appreciated the forms’ simple design features and perceived Smart Paper Technology as time-saving and easy to use. The time-motion study with 273.3 and 224.0 hours of observations before and after introduction of Smart Paper Technology, respectively, confirmed that working time spent on documentation did not increase (27.0% at baseline and 26.4% post-introduction; adjusted p=0.763). Time spent on patient care was not negatively impacted (26.9% at baseline and 37.1% at post-intervention; adjusted p=0.001). Health care providers described positive effects on their accountability for data and service provision relating to the fact that individually signed forms were filled.DiscussionHealth care providers perceived Smart Paper Technology as feasible, easy to integrate and acceptable in their setting, particularly as it did not add time to documentation.

Background Overuse of antibiotics is a major challenge and undermines measures to control drug resistance worldwide. Postnatal women and newborns are at risk of infections and are often prescribed prophylactic antibiotics although there is no evidence to support their universal use in either group. Methods We performed point prevalence surveys in three hospitals in Dar es Salaam, Tanzania, in 2018 to collect descriptive data on antibiotic use and infections, in maternity and neonatal wards. Results Prescribing of antibiotics was high in all three hospitals ranging from 90% (43/48) to 100% (34/34) in women after cesarean section, from 1.4% (1/73) to 63% (30/48) in women after vaginal delivery, and from 89% (76/85) to 100% (77/77) in neonates. The most common reason for prescribing antibiotics was medical prophylaxis in both maternity and neonatal wards. Conclusions We observed substantial overuse of antibiotics in postnatal women and newborns. This calls for urgent antibiotic stewardship programs in Tanzanian hospitals to curb this inappropriate use and limit the spread of antimicrobial resistance.

Background Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. Methods We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. Results Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. Conclusions Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral. Electronic supplementary material The online version of this article (10.1186/s12913-019-4019-z) contains supplementary material, which is available to authorized users.

In many low- and middle-income countries, planning cycles and policy decisions are not always informed by cost evidence, even where relevant and recent cost evidence is available. The Immunization Costing Action Network (ICAN) project was a research and learning community designed to strengthen country capacity to generate immunization cost evidence and to understand and improve the evidence-to-policy linkages for the evidence. We identified key factors that increase the likelihood that health policy makers will use evidence for policy making or planning, which shaped the development of a 6-step evidence to policy and practice (EPP) facilitated process. ICAN used the EPP process in Indonesia, Tanzania, and Vietnam from 2016-2019. The experience resulted in several insights regarding country priorities related to cost evidence and factors that determine uptake. Cost evidence is more likely to be used if it answers a specific policy question prioritized by the immunization program, while the use case is less clear and urgent for routine planning and program management. Nonhealth ministries and subnational stakeholders can provide important perspectives to inform the research and its usability. The use case for evidence should be revisited periodically as divergences from formal planning cycles are common and new policy windows open. Ensuring evidence is available at the right time is critical, even if this requires a sacrifice between rigor and speed. Engaging a small group of stakeholders, rather than an individual, to champion the research may be more effective, and the research has greater legitimacy if it is produced by multidisciplinary country teams. Evidence and messages should be tailored for and packaged targeting different audiences. Going forward, continued support is necessary to bridge the divide between those who generate cost evidence and those who translate evidence for policy and planning decisions.

Background: Strategic health purchasing in low- and middle-income countries has received substantial attention as countries aim to achieve universal health coverage (UHC), by ensuring equitable access to quality health services without the risk of financial hardship. There is little evidence published from Tanzania on purchasing arrangements and what is required for strategic purchasing. This study analyses three purchasing arrangements in Tanzania and gives recommendations to strengthen strategic purchasing in Tanzania. Methods: We used the multi-case qualitative study drawing on the National Health Insurance Fund (NHIF), Social Health Insurance Benefit (SHIB), and improved Community Health Fund (iCHF) to explore the three purchasing arrangements with a purchaser-provider split. Data were drawn from document reviews and results were validated with nine key informant (KI) interviews with a range of actors involved in strategic purchasing. A deductive and inductive approach was used to develop the themes and framework analysis to summarize the data. Results: The findings show that benefit selection for all three schemes was based on the standard treatment guidelines issued by the Ministry of Health. Selection-contracting of the private healthcare providers are based on the location of the provider, the range of services available as stipulated in the scheme guideline, and the willingness of the provider to be contracted. NHF uses fee-for-service to reimburse providers. While SHIB and iCHF use capitation. NHIF has an electronic system to monitor registration, verification, claims processing, and referrals. While SHIB monitoring is done through routine supportive supervision and for the iCHF provider performance is monitored through utilization rates. Conclusion: Enforcing compliance with the contractual agreement between providers-purchasers is crucial for the provision of quality services in an efficient manner. Investment in a routine monitoring system, such as the use of the district health information system which allows effective tracking of healthcare service delivery, and broader population healthcare outcomes.

Additional file 8 “ACC breakdown”. Results by categories of ACC.

Additional file 7 “Sensitivity analyses”. Sensitivity analyses results for microbiological cleanliness.

Summary Background Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data. Methods Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics. Findings We observed 23 471 births and 840 mother–baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3–100) compared with observed coverage of 100% (99·9–100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1–89·5]) vs 99·4% [98·7–99·8] observed), bag-mask ventilation (0·8% [0·4–1·4]) vs 4·4% [1·9–8·1]), and antibiotics for neonatal infection (74·7% [55·3–90·1] vs 96·4% [94·0–98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4–66·8) vs 10·9% [3·8–21·0] observed). “Don’t know” responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8–99·5] vs 99·2% [98·6–99·7] observed), bag-mask ventilation (4·3% [2·1–7·3] vs 5·1% [2·0–9·6] observed), KMC (92·9% [84·2–98·5] vs 100% [99·9–100] observed), and overestimated early breastfeeding (85·9% (58·1–99·6) vs 12·5% [4·6–23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals. Interpretation Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth. Funding Children's Investment Fund Foundation and Swedish Research Council.

Additional file 5 “Tablet façade”. Visual of data collection tool.

Additional file 1 “ToC and Assumptions". Details of the Theory of Change.

Additional file 6 “Layout”. Example of ward layout for data collection.

Additional file 3 “Key hand-touch sites”. Selection of hand-touch sites.

Additional file 9 “Sensitivity and Specificity”. Sensitivity and specificity calculations.

Background Healthcare associated infections (HAI) are estimated to affect up to 15% of hospital inpatients in low-income countries (LICs). A critical but often neglected aspect of HAI prevention is basic environmental hygiene, particularly surface cleaning and linen management. TEACH CLEAN is an educational intervention aimed at improving environmental hygiene. We evaluated the effectiveness of this intervention in a pilot study in three high-volume maternity and newborn units in Dar es Salaam, Tanzania. Methods This study design prospectively evaluated the intervention as a whole, and offered a before-and-after comparison of the impact of the main training. We measured changes in microbiological cleanliness [Aerobic Colony Counts (ACC) and presence of Staphylococcus aureus] using dipslides, and physical cleaning action using gel dots. These were analysed with descriptive statistics and logistic regression models. We used qualitative (focus group discussions, in-depth interviews, and semi-structured observation) and quantitative (observation checklist) tools to measure why and how the intervention worked. We describe these findings across the themes of adaptation, fidelity, dose, reach and context. Results Microbiological cleanliness improved during the study period (ACC pre-training: 19%; post-training: 41%). The odds of cleanliness increased on average by 1.33 weekly during the pre-training period (CI = 1.11–1.60), and by 1.08 (CI = 1.03–1.13) during the post-training period. Cleaning action improved only in the pre-training period. Detection of S. aureus on hospital surfaces did not change substantially. The intervention was well received and considered feasible in this context. The major pitfalls in the implementation were the limited number of training sessions at the hospital level and the lack of supportive supervision. A systems barrier to implementation was lack of regular cleaning supplies. Conclusions The evaluation suggests that improvements in microbiological cleanliness are possible using this intervention and can be sustained. Improved microbiological cleanliness is a key step on the pathway to infection prevention in hospitals. Future research should assess whether this bundle is cost-effective in reducing bacterial and viral transmission and infection using a rigorous study design.

Additional file 2 “SQUIRE guidelines”. SQUIRE checklist.

Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted

Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels. Methods: EN-BIRTH is an observational study including >20000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses. Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes. Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers. Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.

Context documentation. (DOCX 183 kb)

Example of a run-chart. (DOCX 221 kb)

Implementation strategy. (DOCX 275 kb)

Interview guide â event narrative newborn death. (DOCX 42 kb)

Interview guide â event narrative maternal illness. (DOC 85 kb)

Maps of the implementation and comparison areas in Uganda and Tanzania. (DOCX 367 kb)

Interview guide â event narrative maternal death. (DOC 84 kb)

Definitions. (DOCX 20 kb)