1. Informal payments and the quality of health care: the case of Tanzania Seminar CMI/PUSER, 28 November 2006 Aziza Mwisongo (NIMR) and Ottar Mæstad (CMI)

2. Background and purpose Health worker motivation and performance Performance issues –Clinical performance –Patient courtesy –Corruption –Absenteeism Photo: Magnus Hatlebakk

3. Informal payments and health outcomes Informal payments ?? UtilisationQuality of care Health

4. Methodology 8 focus groups –4 urban, 4 rural –One cadre per group Doctors Clinical Officers Nurses Assistants –One worker per facility in each group –Each facility represented in several groups –Language: Swahili

5. Participant characteristics Number of participants58 Age (mean)42 yrs Female share60 % Level of care Hospital48 % Health centre22 % Dispensary28 % Years in health sector (mean)19 yrs Years in current position (mean)10 yrs Employer Government74 % Private for profit21 % Faith based5 %

6. Types of informal payments Bypass a queue Pay for care Get drugs and supplies –Artificial shortages –In-facility drugs shop Gifts of appreciation Pay for illegal services (abortion) Pay for improved bargaining power in the household

7. Characteristics of the system All groups of health workers are involved Sharing of informal incomes –Limited or absent within cadre –More common across cadres Perceived unfairness of the allocation of payments Less informal payments in private facilities

8. Competition for payments may increase quality Therefore, the patient will decide to give money to the one who has a good heart and who can help you rather than the one who has a difficult heart Nurse, urban

9. Withhold care in order to bargain for a larger share of payments if the nurses know that a certain doctor has already received a bribe then the nurses start to avoid or give less attention to that patient Doctor, rural

10. Withhold care in order to signal that quality has a price sometimes when I was accompanying the patients to Muhimbili, the situation I saw there it’s really shocking. You meet with the nurse assistant, she abuses you, she refuses to receive a patient, …and even if she will end up in receiving the patient, she does it by accompanying with the abuses Nurse, urban …if you go at the health facility you’ll find a nurse with the ugly face who is just singing without showing any sense of care… Nurse, urban

11. Stealing – negative (but small?) impact on quality …they pretend that there are the drugs that are missing… Because the patient wants the service s/he will end up asking “for how much are they sold?” and s/he can say they are sold for 3,000/= or 4,000/= so if you give me this money I can get them. Once s/he get those monies then s/he just take the drugs and send them to the patients … S/he does not buy them, the drugs are there. Nurses, urban

12. Frustrations due to perceived unfairness may reduce quality …if I am not with good heart and have seen that a doctor has been bribed but I have not received any share from it, I may, if supposed to give six tablets, give four... if angry I may even give two tablets. Medical assistant, rural

13. Non-corrupt workers may withhold care if you decide to take care of that patient to make sure that you want to get proper diagnosis, then people will start to think that the doctor has got something Clinical officer, rural

14. The socio-economic distribution of quality care …it happens that the amount of money they gave you is very small say it is 500/=, but the patient will say: “I gave that nurse my money”. S/he will hang on you to the extent that you’ll regret for taking that money. Medical assistant, urban

15. Keeping health workers at their duty posts may increase quality Reduced attrition Reduced need for second jobs