title: The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis.
abstract: Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services.
  
  
  
  A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries' education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women's decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants.
  
  
  
  Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home.
  
  
  
  To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as giving women insurance cards only does not guarantee facility-based delivery.
authors.affiliation: Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania. ajoachim@ihi.or.tz.
authors.forename: August
authors.initials: A
authors.lastname: Kuwawenaruwa
authors.affiliation: Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
authors.forename: Gemini
authors.initials: G
authors.lastname: Mtei
authors.affiliation: Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
authors.forename: Jitihada
authors.initials: J
authors.lastname: Baraka
authors.affiliation: Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
authors.forename: Kassimu
authors.initials: K
authors.lastname: Tani
mesh_terms: D000328:Adult; D002648:Child; D002675:Child, Preschool; D003657:Decision Making; D036861:Delivery, Obstetric / Q000379:methods*; D004522:Educational Status; D005260:Female; D000069576:Health Equity; D006268:Health Facilities / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D006700:Home Childbirth; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007348:Insurance, Health; D000068101:Maternal-Child Health Services / Q000191:economics / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care; D011247:Pregnancy; D011248:Pregnancy Complications; D036301:Qualitative Research; D013636:Tanzania
keywords: Demand-side financing; Equity; Insurance; Place of delivery; Tanzania; Targeting mechanism