title: Beyond antimalarial stock-outs: implications of health provider compliance on out-of-pocket expenditure during care-seeking for fever in South East Tanzania.
abstract: BACKGROUND
  To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania.
  
  
  METHODS
  We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility.
  
  
  RESULTS
  Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding.
  
  
  CONCLUSIONS
  System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability.
authors.affiliation: Swiss Tropical and Public Health Institute, Basel, Switzerland. i.mikkelsen-lopez@unibas.ch.
authors.forename: Inez
authors.initials: I
authors.lastname: Mikkelsen-Lopez
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Tediosi
authors.forename: Gumi
authors.initials: G
authors.lastname: Abdallah
authors.forename: Mustafa
authors.initials: M
authors.lastname: Njozi
authors.forename: Baraka
authors.initials: B
authors.lastname: Amuri
authors.forename: Rashid
authors.initials: R
authors.lastname: Khatib
authors.forename: Fatuma
authors.initials: F
authors.lastname: Manzi
authors.forename: Don
authors.initials: D
authors.lastname: de Savigny
mesh_terms: D000962:Antimalarials / Q000191:economics / Q000600:supply & distribution*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000191:economics / Q000600:supply & distribution*; D003669:Deductibles and Coinsurance / Q000191:economics / Q000706:statistics & numerical data; D004338:Drug Combinations; D016527:Drug Costs / Q000706:statistics & numerical data*; D004983:Ethanolamines / Q000191:economics / Q000600:supply & distribution*; D005191:Family Characteristics; D005334:Fever / Q000188:drug therapy* / Q000191:economics; D005382:Financing, Personal / Q000706:statistics & numerical data*; D005449:Fluorenes / Q000191:economics / Q000600:supply & distribution*; D017048:Health Care Costs / Q000706:statistics & numerical data; D005102:Health Expenditures / Q000706:statistics & numerical data; D006291:Health Policy; D006801:Humans; D007348:Insurance, Health / Q000191:economics / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013636:Tanzania / Q000453:epidemiology
chemical_list: D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes