BackgroundEnhancingquality of health care service provision and delivery in public sectors indeveloping countries like Tanzania is a key prerequisite to increaseutilization and sustainability of health care services. Tanzania is one of thedeveloping countries facing major socioeconomic challenges. Internal factorslike poor infrastructure, low level of education, poverty and diseases are themain contributors of the existing challenges.
Apart from the efforts taking bythe country to implement the Millennium Development Goals (MGDs) set by theUnited Nations to eradicate poverty, mortality and combat diseases, asimportant for the country to improve the overall state of wellbeing of thesocieties, the provision of health care, particularly in rural areas and facilities,was severely affected after the economic recession in the 1970s, and 1980swhich resulted in an overall deterioration of health care services (Robert,Eastwood and Michael, Lipton, 2000). This forced the Tanzania government tointroduce cost-sharing in 1993 and following that, instituting other financingoptions such as a National Health Insurance and a Community Health fund. Again,very few populations of Tanzanian citizens, especially in rural areas haveaccess to health insurance due to difficulties to pay for services.Introduction Theproblem of urban-rural health care inequality takes various forms, includingpre-mature death, weak health status, humiliation, discrimination, poverty, andexclusion from opportunities and life chances. The agenda of inequality acrossthe World has been taken in the development debates within many countries. Theevidence from 2014 Oxfam campaign and movement to fight inequalities showsthat, 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 worsewhereby the richest 1% owns as much wealth of the poorest 91%, which meansthat, the richest 6 individuals in East Africa own as much as half the region’spopulation of 66 million people (Goran, 2013).
Moreover, the health careinequality between urban and rural areas causes the existence of differences inthe quality of health and health care across different populations (ColoradoDevelopment of Public Health and Environment, 2011). Furthermore, the healthcare inequalities may result presence of disease’s health outcomes, or accessto health care between populations with different race, ethnicity, sexualorientation or socioeconomic status (U.S Department of Health and HumanServices, 2010).
For these reasons, the study tends to assess the impacts ofurban-rural health care inequality on the increases cases of morbidity andmortality in Tanzania rural areas.ProblemStatementThegovernment of Tanzania is taking significant efforts through public and privateproviders to ensure the provision and delivery of health care services to itscitizens. The data from the Tanzania Bureau of Statistics (2015) shows that,there are about 6,549 dispensaries, 718 health facilities and 252 Public andPrivate hospitals throughout the country.
However, the country is facingchallenges of limited access to health infrastructures including; trainedhealth care workers, inpatient hospital care, poor transports, and longdistance between one health center to another that still hinder the quality ofPublic health between urban and rural areas. On the other hand, few populationsof Tanzanian citizens have access to health insurance, especially in ruralareas due to financial constraints that make them unable to pay for services.Moreover, Tanzanians in rural areas, especially pregnant women, older women, divorcedwomen, separated or widows, and citizens who require emergence treatments arefacing difficult to find the transports to reach health centers that are farfrom their households (Tanzania Demographic and Health Survey, 2015/2016). Thesurvey also admits that, access to health services in Tanzania is furtherlimited by poverty level, ethnicity, and location. The study, therefore, tendsto assess the impacts of urban-rural health care inequality to the increase ofmorbidity and mortality in rural areas.Research Objectives The main objective of the study isto assess the impacts of urban-rural health care inequality on the increases ofmorbidity and mortality case in Tanzania rural areas.
Specific Objective· Identify dimensions in which urban-ruralhealth care inequalities persists.Research Questions1. Whatare the health differences in term of morbidity and mortality exist betweenTanzania’s urban and rural areas?2.
Arethere any dimensions in which urban-rural health care inequality exists?Scope and Area of the Study The study will be carried out inDar-es-salaam region and Mtwara region in Tanzania. These two regions compriseone urban region, which is Dar-es-salaam and one rural region, which is Mtwararegion. The reason of choosing these two regions is to make a comparisonbetween the two in order to assess the inequalities of health care servicesthat exist. Furthermore, the study will focus only on the information from the2015/2016 Tanzania Demographic and Health Survey. Significance of the StudyTheresults of the study will provide relevant information to policy makers andlocal development planners to put emphasis on the development of healthinfrastructures in both rural and urban areas. Furthermore, the study willprovide additional information about the impacts of rural-urban health careinequality to the increases of morbidity and mortality case in the rural areas,hence proposed solution will be recommended by the study to the Ministry ofhealth and the government in general, and lastly, the study will help to addknowledge and becomes a reference for further researches.
Literature Review HealthInequality refers to differences in the health of individuals or groups, thusany measurable aspect of health that varies across individuals or according tosocially relevant groupings can be called a health inequality (Kawachi I,Subramanian SV, Almeida-Filho N J Epidemiol Community Health, 2002). The studyis going to look at inequality in terms of access to health care, morbidity andmortality rate, and health insurance coverage as follows;Access to HealthCare: The Tanzania Health Sector Strategic Plan (2013) shows that, nearlyevery child has access to immunization services in Tanzania, butchallenges still remain in improvingaccess to maternity services, especially the completion of ANC visits, andskilled birth deliveries are still very low, while health facilities includingthe presence of enough human resources, essential drugs, and medical suppliesare major challenges especially in rural areas. The study reports only 36% ofpregnant women had at least 4 ANC visits in 2012, while only 58% had a skilled birthattendance. 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 adispensary or the health center. Furthermore, the study shows that Tanzania isstill facing challenges in increase the number of health centers and levelfacilities. In addition, the study shows about 24% of the essential drugs arenot available in public health facilities and nearly 41% of the population werenot able to obtain the prescribed drugs from the facilities they visited in2013, whereas the situation worsen in rural areas. On the other hand, the available informationfrom the survey report shows that on the average for the country, has less than1 per capita outpatient visit per year compared to the proposed benchmark of 4visits per capital per year.
Finally, the results from there is evidence ofpoor satisfaction with health services provided in the country, whereas only58% of the individuals who visited a health provider in 2010 were at leastsatisfied with the services provided at the visited facilities (National PanelSurvey, 2010). Mortality andMorbidity rate: According to Macha, J., Harris, B., Garshong, B., Ataguba,J. E., Akazili, J.
, Kuwawenaruwa, A., & Borghi, J. (2012) admits that theTanzania country is doing well in terms of number of child access indicators,but still, the country is facing challenges in the improvement of maternalhealth and other health system ‘s indicators, including availability of humanresources for health facilities, drugs and medical supplies, especially inrural areas. Their study goes deep by mention that, though the Tanzaniagovernment has improved to control under-five mortality, still the problem ofmaternal mortality and malaria morbidity are still not enough controlledespecially in the rural areas. Therborn, Goran (2013) admits that, the burdenof disease in Tanzania is high with communicable diseases. Communicable, maternal,perinatal and malnutrition condition accounts for 65% of total death in allages, with HIV/AIDS, tuberculosis and malaria are among the most commondiseases. In Tanzania non-communicable diseases are estimated to account for31% 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 about757,000 among males and 588,000 among females in Tanzania.
The TanzaniaDemographic and Health Survey report of (2005-2010) shows that, 42 percent ofunder-five years children in Tanzania are too short for their age or arestunted. 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-fivemortality worse within the poorest households whereby 103 children ofunder-five years of age are dying comparing to 83 within the richest householdsper 1,000 live births. This means that 1child out of 10 born within the pooresthouseholds have a very low chance of survival compared to those have been bornwithin the richest households.Health Insurancecoverage: According to Mtei, G., Makawia, S., Ally, M., Kuwawenaruwa, A.
, Meheus,F., & Borghi, J. (2012), in their study while assessing the equity inhealth care financing and benefit distribution in Tanzania found that, about15% of the total population have some form of health insurance coverage,whereas formal sector insurance coverage accounts for about 7.1% of thepopulation, while the informal sector insurance coverage is about 6.9%. Thisresult proves that there is very low level compare to the population of morethan 80% working in the informal sector. The situation is worsening to therural areas where the largest populations are unemployed who engage in theinformal sector.
The disparity in health insurance was caused by the legalrequirements of most health insurance companies, which required to registeronly formal workers. Many studies have beendone in relation to health care inequality in the area of income between urbanand rural communities, but no study has been done in relation to the impact ofurban-rural inequality on the increases of morbidity and mortality cases inrural Tanzania areas. For this reason the study tends to assess the impacts ofhealth care inequalities between the urban and rural Tanzania areas withspecial focus on the issue of disparities in access to health care whichinclude; structural barriers, legal barriers, lack of human resources, healthcare financing system and the scarcity of providers proposed to be used tomeasure the impacts.Methodology Thestudy aims to assess the impacts of urban-rural health care inequality on theincreases of morbidity and mortality cases in rural areas. Quantitative methodis proposed to be used for the study to assess the situation by analyzing theexisting situation through experiences within urban and rural communities.
Thestudy proposed to use primary data through contextual survey design, whereasstructured questionnaires are proposed to be used to assess the impacts thatwere not well studied before to discover new insights. The study will be conducted inDar-es-salaam and Mtwara regions which present urban and rural regions. Thesestudy areas are selected as to present two sides in which the study is going tomake a comparison in order to measure the impacts of the study. The targetpopulation will be the public hospitals, private hospitals and dispensariesexisting within the two regions as well as the households within thesecommunities. This will help to understand the existing differences between theurban and rural health care providers.
The hospitals eligible for the studywill be those that operate for more than three years. This will help to obtainmore information from the organizations that operated relatively longer in theareas. The questionnaires proposed to be conductedwith the management staffs of the hospitals and dispensaries. Thequestionnaires 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, 100will target hospitals, and dispensaries, while 300 respondents proposed totarget the households within the two regions. The questionnaires will bedistributed by trained staffs using the national language to make the datacollection process feasible. The study will employ conveniencesampling for selection of 100 respondents hospitals and dispensaries, while selectionof 300 households within the two regions will be selected through randomselection.
During the distribution of questionnaires,the proper ethical considerations will be employed, including informingparticipants the purpose of the study and confidentiality of the information.Additionally, the consent of the participants will be required to answer thequestionnaires.Time Table