Promoting Universal Health Coverage in Tanzania: Towards Improved Health Service Quality and Financial Protection Inauguraldissertation zur Erlangung der Würden eines Doktors der Philosophie vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel von Sabine Renggli aus Entlebuch (LU) Basel, 2017 Originaldokument gespeichert auf dem Dokumentenserver der Universität Basel edoc.unibas.ch Dieses Werk ist lizenziert unter einer „Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License“. Die vollständige Lizenz kann unter creativecommons.org/licenses/by-nc-nd/4.0/ eingesehen werden. Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät auf Antrag von Herrn Prof. Dr. Christian Lengeler und Frau Dr. Josephine Borghi. Basel, den 20. Juni 2017 Prof. Dr. Martin Spiess Dekan Dedicated to the people of Tanzania – Kwa Watanzania iii Table of contents Table of contents Table of contents ................................................................................................................... iv List of figures ........................................................................................................................ vii List of tables .......................................................................................................................... ix List of abbreviations .............................................................................................................. xi Acknowledgement ............................................................................................................... xiii Summary .............................................................................................................................. xv 1. Introduction .................................................................................................................... 1 1.1 The concept of Universal Health Coverage ............................................................. 1 1.2 Basics of health system research ............................................................................ 3 1.3 Overview of the Tanzanian health system ............................................................... 5 1.4 Universal Health Coverage in Tanzania .................................................................. 9 1.4.1 Health service coverage ................................................................................... 9 1.4.2 Financial protection coverage ..........................................................................17 1.4.3 Equity in coverage ...........................................................................................19 1.5 The Initiative to Strengthen Affordability and Quality of Healthcare ........................22 1.5.1 Assessing and improving quality of primary healthcare ...................................23 1.5.2 Strengthening and expanding coverage of Community Health Funds .............24 2. Aim and objectives ........................................................................................................25 2.1 Aim .........................................................................................................................25 2.2 Objectives ..............................................................................................................25 3. Methods and study setting ............................................................................................26 3.1 Methods .................................................................................................................26 3.2 Study setting ..........................................................................................................28 3.3 Ethical considerations ............................................................................................29 4. Embedding systematic quality assessments in supportive supervision at primary healthcare level: application of an electronic Tool to Improve Quality of Healthcare in Tanzania ..............................................................................................................................30 4.1 Abstract ..................................................................................................................31 4.2 Introduction ............................................................................................................32 4.3 Methods .................................................................................................................36 4.4 Results ...................................................................................................................49 4.5 Discussion ..............................................................................................................55 4.6 Conclusion .............................................................................................................58 4.7 Acknowledgment ....................................................................................................59 iv Table of contents 4.8 Declarations ...........................................................................................................60 5. Towards improved health service quality in Tanzania: Appropriateness of an electronic tool to assess quality of primary healthcare ..........................................................................61 5.1 Abstract ..................................................................................................................62 5.2 Introduction ............................................................................................................63 5.3 Methods .................................................................................................................66 5.4 Results ...................................................................................................................72 5.5 Discussion ..............................................................................................................80 5.6 Conclusions............................................................................................................85 5.7 Acknowledgement ..................................................................................................86 6. Towards improved health service quality in Tanzania: Contribution of a supportive supervision approach to increased quality of primary healthcare ..........................................87 6.1 Abstract ..................................................................................................................88 6.2 Introduction ............................................................................................................89 6.3 Methods .................................................................................................................92 6.4 Results ...................................................................................................................99 6.5 Discussion ............................................................................................................ 107 6.6 Conclusion ........................................................................................................... 111 6.7 Acknowledgement ................................................................................................ 112 7. Towards improved health service quality in Tanzania: An approach to increase cost- effectiveness of routine supportive supervision................................................................... 113 7.1 Abstract ................................................................................................................ 114 7.2 Introduction .......................................................................................................... 115 7.3 Methods ............................................................................................................... 119 7.4 Results ................................................................................................................. 125 7.5 Discussion ............................................................................................................ 140 7.6 Conclusion ........................................................................................................... 145 7.7 Acknowledgement ................................................................................................ 146 7.8 Supplementary data ............................................................................................. 147 8. Administrating the Tanzanian Community Health Fund within a complex system ....... 150 8.1 Abstract ................................................................................................................ 151 8.2 Introduction .......................................................................................................... 152 8.3 Methods ............................................................................................................... 156 8.4 Results ................................................................................................................. 161 8.5 Discussion ............................................................................................................ 172 8.6 Conclusion ........................................................................................................... 178 8.7 Acknowledgment .................................................................................................. 179 v Table