Background may result presence of disease’s health outcomes,


quality of health care service provision and delivery in public sectors in
developing countries like Tanzania is a key prerequisite to increase
utilization and sustainability of health care services. Tanzania is one of the
developing countries facing major socioeconomic challenges. Internal factors
like poor infrastructure, low level of education, poverty and diseases are the
main contributors of the existing challenges. Apart from the efforts taking by
the country to implement the Millennium Development Goals (MGDs) set by the
United Nations to eradicate poverty, mortality and combat diseases, as
important for the country to improve the overall state of wellbeing of the
societies, the provision of health care, particularly in rural areas and facilities,
was severely affected after the economic recession in the 1970s, and 1980s
which resulted in an overall deterioration of health care services (Robert,
Eastwood and Michael, Lipton, 2000). This forced the Tanzania government to
introduce cost-sharing in 1993 and following that, instituting other financing
options such as a National Health Insurance and a Community Health fund. Again,
very few populations of Tanzanian citizens, especially in rural areas have
access to health insurance due to difficulties to pay for services.

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problem of urban-rural health care inequality takes various forms, including
pre-mature death, weak health status, humiliation, discrimination, poverty, and
exclusion from opportunities and life chances. The agenda of inequality across
the World has been taken in the development debates within many countries. The
evidence from 2014 Oxfam campaign and movement to fight inequalities shows
that, 85 richest people hold as much as wealth of half of the World’s population.
In East African countries including Tanzania, the differences are even worse
whereby the richest 1% owns as much wealth of the poorest 91%, which means
that, the richest 6 individuals in East Africa own as much as half the region’s
population of 66 million people (Goran, 2013). Moreover, the health care
inequality between urban and rural areas causes the existence of differences in
the quality of health and health care across different populations (Colorado
Development of Public Health and Environment, 2011). Furthermore, the health
care inequalities may result presence of disease’s health outcomes, or access
to health care between populations with different race, ethnicity, sexual
orientation or socioeconomic status (U.S Department of Health and Human
Services, 2010). For these reasons, the study tends to assess the impacts of
urban-rural health care inequality on the increases cases of morbidity and
mortality in Tanzania rural areas.


government of Tanzania is taking significant efforts through public and private
providers to ensure the provision and delivery of health care services to its
citizens. The data from the Tanzania Bureau of Statistics (2015) shows that,
there are about 6,549 dispensaries, 718 health facilities and 252 Public and
Private hospitals throughout the country. However, the country is facing
challenges of limited access to health infrastructures including; trained
health care workers, inpatient hospital care, poor transports, and long
distance between one health center to another that still hinder the quality of
Public health between urban and rural areas. On the other hand, few populations
of Tanzanian citizens have access to health insurance, especially in rural
areas due to financial constraints that make them unable to pay for services.
Moreover, Tanzanians in rural areas, especially pregnant women, older women, divorced
women, separated or widows, and citizens who require emergence treatments are
facing difficult to find the transports to reach health centers that are far
from their households (Tanzania Demographic and Health Survey, 2015/2016). The
survey also admits that, access to health services in Tanzania is further
limited by poverty level, ethnicity, and location. The study, therefore, tends
to assess the impacts of urban-rural health care inequality to the increase of
morbidity and mortality in rural areas.

Research Objectives

            The main objective of the study is
to assess the impacts of urban-rural health care inequality on the increases of
morbidity and mortality case in Tanzania rural areas.

Specific Objective

Identify dimensions in which urban-rural
health care inequalities persists.

Research Questions

1.      What
are the health differences in term of morbidity and mortality exist between
Tanzania’s urban and rural areas?

2.      Are
there any dimensions in which urban-rural health care inequality exists?

Scope and Area of the Study

            The study will be carried out in
Dar-es-salaam region and Mtwara region in Tanzania. These two regions comprise
one urban region, which is Dar-es-salaam and one rural region, which is Mtwara
region. The reason of choosing these two regions is to make a comparison
between the two in order to assess the inequalities of health care services
that exist. Furthermore, the study will focus only on the information from the
2015/2016 Tanzania Demographic and Health Survey.

Significance of the Study

results of the study will provide relevant information to policy makers and
local development planners to put emphasis on the development of health
infrastructures in both rural and urban areas. Furthermore, the study will
provide additional information about the impacts of rural-urban health care
inequality to the increases of morbidity and mortality case in the rural areas,
hence proposed solution will be recommended by the study to the Ministry of
health and the government in general, and lastly, the study will help to add
knowledge and becomes a reference for further researches.


Literature Review

Inequality refers to differences in the health of individuals or groups, thus
any measurable aspect of health that varies across individuals or according to
socially relevant groupings can be called a health inequality (Kawachi I,
Subramanian SV, Almeida-Filho N J Epidemiol Community Health, 2002). The study
is going to look at inequality in terms of access to health care, morbidity and
mortality rate, and health insurance coverage as follows;

Access to Health
Care: The Tanzania Health Sector Strategic Plan (2013) shows that, nearly
every child has access to immunization services in Tanzania, but
challenges  still remain in improving
access to maternity services, especially the completion of ANC visits, and
skilled birth deliveries are still very low, while health facilities including
the presence of enough human resources, essential drugs, and medical supplies
are major challenges especially in rural areas. The study reports only 36% of
pregnant women had at least 4 ANC visits in 2012, while only 58% had a skilled birth
attendance. Moreover, the survey reported the problem of few health centers,
which force patients walk for long distance looking for health care services.
The survey shows that, about 75% of the population live within 6km to a
dispensary or the health center. Furthermore, the study shows that Tanzania is
still facing challenges in increase the number of health centers and level
facilities. In addition, the study shows about 24% of the essential drugs are
not available in public health facilities and nearly 41% of the population were
not able to obtain the prescribed drugs from the facilities they visited in
2013, whereas the situation worsen in rural areas.  On the other hand, the available information
from the survey report shows that on the average for the country, has less than
1 per capita outpatient visit per year compared to the proposed benchmark of 4
visits per capital per year. Finally, the results from there is evidence of
poor satisfaction with health services provided in the country, whereas only
58% of the individuals who visited a health provider in 2010 were at least
satisfied with the services provided at the visited facilities (National Panel
Survey, 2010).

Mortality and
Morbidity rate: According to Macha, J., Harris, B., Garshong, B., Ataguba,
J. E., Akazili, J., Kuwawenaruwa, A., & Borghi, J. (2012) admits that the
Tanzania country is doing well in terms of number of child access indicators,
but still, the country is facing challenges in the improvement of maternal
health and other health system ‘s indicators, including availability of human
resources for health facilities, drugs and medical supplies, especially in
rural areas. Their study goes deep by mention that, though the Tanzania
government has improved to control under-five mortality, still the problem of
maternal mortality and malaria morbidity are still not enough controlled
especially in the rural areas. Therborn, Goran (2013) admits that, the burden
of disease in Tanzania is high with communicable diseases. Communicable, maternal,
perinatal and malnutrition condition accounts for 65% of total death in all
ages, with HIV/AIDS, tuberculosis and malaria are among the most common
diseases. In Tanzania non-communicable diseases are estimated to account for
31% of all deaths and remaining 8% occur due to injuries (WHO, 2012). In 2008,
the (WHO) showed that non-communicable diseases contributes to death to about
757,000 among males and 588,000 among females in Tanzania. The Tanzania
Demographic and Health Survey report of (2005-2010) shows that, 42 percent of
under-five years children in Tanzania are too short for their age or are
stunted. Stunting is chronic in urban areas (42%) than (32%) of urban areas.
The study conducted by Therborn, Goran (2013) reports that, the situation of under-five
mortality worse within the poorest households whereby 103 children of
under-five years of age are dying comparing to 83 within the richest households
per 1,000 live births. This means that 1child out of 10 born within the poorest
households have a very low chance of survival compared to those have been born
within the richest households.

Health Insurance
coverage: According to Mtei, G., Makawia, S., Ally, M., Kuwawenaruwa, A., Meheus,
F., & Borghi, J. (2012), in their study while assessing the equity in
health care financing and benefit distribution in Tanzania found that, about
15% of the total population have some form of health insurance coverage,
whereas formal sector insurance coverage accounts for about 7.1% of the
population, while the informal sector insurance coverage is about 6.9%. This
result proves that there is very low level compare to the population of more
than 80% working in the informal sector. The situation is worsening to the
rural areas where the largest populations are unemployed who engage in the
informal sector. The disparity in health insurance was caused by the legal
requirements of most health insurance companies, which required to register
only formal workers.

Many studies have been
done in relation to health care inequality in the area of income between urban
and rural communities, but no study has been done in relation to the impact of
urban-rural inequality on the increases of morbidity and mortality cases in
rural Tanzania areas. For this reason the study tends to assess the impacts of
health care inequalities between the urban and rural Tanzania areas with
special focus on the issue of disparities in access to health care which
include; structural barriers, legal barriers, lack of human resources, health
care financing system and the scarcity of providers proposed to be used to
measure the impacts.


study aims to assess the impacts of urban-rural health care inequality on the
increases of morbidity and mortality cases in rural areas. Quantitative method
is proposed to be used for the study to assess the situation by analyzing the
existing situation through experiences within urban and rural communities. The
study proposed to use primary data through contextual survey design, whereas
structured questionnaires are proposed to be used to assess the impacts that
were not well studied before to discover new insights.

            The study will be conducted in
Dar-es-salaam and Mtwara regions which present urban and rural regions. These
study areas are selected as to present two sides in which the study is going to
make a comparison in order to measure the impacts of the study. The target
population will be the public hospitals, private hospitals and dispensaries
existing within the two regions as well as the households within these
communities. This will help to understand the existing differences between the
urban and rural health care providers. The hospitals eligible for the study
will be those that operate for more than three years. This will help to obtain
more information from the organizations that operated relatively longer in the

            The questionnaires proposed to be conducted
with the management staffs of the hospitals and dispensaries. The
questionnaires will also be distributed within households of the two regions,
since they have detailed information for the study. The study proposed to  use 400 respondents. Among these respondents, 100
will target hospitals, and dispensaries, while 300 respondents proposed to
target the households within the two regions. The questionnaires will be
distributed by trained staffs using the national language to make the data
collection process feasible.

            The study will employ convenience
sampling for selection of 100 respondents hospitals and dispensaries, while selection
of 300 households within the two regions will be selected through random

            During the distribution of questionnaires,
the proper ethical considerations will be employed, including informing
participants the purpose of the study and confidentiality of the information.
Additionally, the consent of the participants will be required to answer the

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