title: User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania.
abstract: OBJECTIVE
  To identify the main drivers of costs of facility delivery and the financial consequences for households among rural women in Tanzania, a country with a policy of delivery fee exemptions.
  
  
  METHODS
  We selected a representative sample of households in a rural district in western Tanzania. Women who given birth within 5 years were asked about payments for doctor's/nurse's fees, drugs, non-medical supplies, medical tests, maternity waiting home, transport and other expenses. Wealth was assessed using a household asset index. We estimated the proportion of women who cut down on spending or borrowed money/sold household items to pay for delivery in each wealth group.
  
  
  RESULTS
  In all, 73.3% of women with facility delivery reported having made out-of-pocket payments for delivery-related costs. The average cost was 6272 Tanzanian shillings (TZS), [95% Confidence Interval (CI): 4916, 7628] or 5.0 United States dollars. Transport costs (53.6%) and provider fees (26.6%) were the largest cost components in government facilities. Deliveries in mission facilities were twice as expensive as those in government facilities. Nearly half (48.3%) of women reported cutting down on spending or borrowing money/selling household assets to pay for delivery, with the poor reporting this most frequently.
  
  
  CONCLUSIONS
  Out-of-pocket payments for facility delivery were substantial and were driven by high transport costs, unofficial provider payments, and preference for mission facilities, which levy user charges. Novel approaches to financing maternal health services, such as subsidies for transport and care from private providers, are required to reduce the cost barriers to attended delivery.
authors.affiliation: Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA. mkruk@umich.edu
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Kruk
authors.forename: Godfrey
authors.initials: G
authors.lastname: Mbaruku
authors.forename: Peter C
authors.initials: PC
authors.lastname: Rockers
authors.forename: Sandro
authors.initials: S
authors.lastname: Galea
mesh_terms: D036861:Delivery, Obstetric / Q000191:economics*; D003906:Developing Countries; D005249:Fees and Charges; D005260:Female; D005382:Financing, Personal / Q000191:economics*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008427:Maternal Health Services / Q000191:economics; D011203:Poverty; D011247:Pregnancy; D011295:Prenatal Care / Q000191:economics; D012424:Rural Population; D013636:Tanzania