In our analysis of 2015–2016 Tanzania DHS data, we found that the vast majority of modern FP users, approximately 85%, reported free FP at public sector facilities. In the four poorest wealth quintiles, public facilities (government hospitals, government health centers, and government dispensaries) were the source for the majority of current contraceptive methods. In all but the richest wealth quintile, injections and implants were the most commonly used modern FP methods. These findings suggest that most providers within public sector facilities in Tanzania are adhering to enacted policies, which stipulate that FP methods and services should be provided for free at public facilities [6, 7]. These findings contrast with those presented by Radovich and colleagues in their analysis of 2014 Kenya DHS data, in which they found that only half of public sector FP users reported that they obtained their method for free despite policies stating that FP methods should be provided for free at public sector facilities .
However, implementation of this important policy can still be improved as we found that 22% of injectable users and 10% of implant users who visited public facilities reported payment for their current method at a public sector facility. At government dispensaries, one out of every six women reported informal payments for FP methods and/or services. Furthermore, one in every four women who obtained an injectable at a government dispensary was asked for informal payments. These findings are especially meaningful, because government dispensaries are the most popular source and implants and injectables are the most popular methods among women in the lowest wealth quintile.
It may be that informal payments arise, because providers are targeting particular patients (e.g., women with low socioeconomic status); however, it may also be that providers at particular facility types are more likely to leverage informal payments, regardless of patient demographics; for example, providers working at government dispensaries may be more likely to be located in a remote area with limited supervision and/or be the sole healthcare provider at their facility, both of which may facilitate solicitation of unsanctioned informal payments. Delineating between these possibilities is outside the scope of the present analysis, but should be a focus of future work examining the etiology of informal payments for FP.
The informal payments reported for injectables at public facilities may be prohibitive for women living around and below the poverty line. In 2018, 14 million people lived below the Tanzanian poverty line of TSh 49,320 per adult per month (about 21 USD) and 26 million (approximately 49% of the population in Tanzania) lived below the international poverty line of 1.90 USD per person per day . Among those currently using injectables who paid for their method at a public sector facility, the mean cost was TSh 1420, or approximately 0.61 USD. Though this cost may seem trivial to people not living in poverty, for millions of women in Tanzania, an informal payment of 0.61 USD for an injectable would be a challenging sum to procure.
Demand for and use of implants has increased rapidly in many countries in sub-Saharan Africa over the last decade . In this analysis, we found that, among those who paid for their current method at a public sector facility, the mean informal payment for implants was TSh 4127 (approximately 1.78 USD), which is 3 times the mean informal payment for injectables among those who reported paying any amount for FP at a public facility. This informal payment may be prohibitive for many women. Thus, it is possible that informal payments for implants might be suppressing the true demand for this highly effective method in Tanzania.
Provider demand of informal payments for perinatal healthcare is common in many countries around the world and some studies have focused on their impact on sexual and reproductive health services [10, 12, 23,24,25,26,27,28,29,30]. The frequency of informal payments differs substantially by country, ranging from 3% in Peru to 96% in Pakistan . While informal payments are quite common across South Asian countries, payment frequency varies widely by country in East Asia, Latin America, and Eastern Europe; in sub-Saharan Africa, evidence from studies in Uganda, Mozambique and Ethiopia suggests that informal payments to public sector providers are common . The size of these informal payments varies, but can add up to a formidable sum, especially for patients with low socioeconomic status and for those who are charged informal payments at several points while accessing care. Tragically, knowledge that providers may solicit informal payments when patients seek care may prevent care seeking altogether, particularly for patients who have few financial resources [23, 25, 29, 30].
The literature suggests several reasons for informal payments in public sector facilities, which may be relevant to the Tanzanian context. Tumlinson and colleagues analyzed in-depth semi-structured interviews with 20 public and private sector reproductive healthcare workers in Kenya, and found that providers cited low public sector wages as a chief reason that providers ask patients for informal payments . Providers reported that senior staff often worked together to solicit informal payments and explained that patients might be charged informal payments, because they do not know which services should be provided free of charge. These findings suggest both individual-level and structural-level levers for reducing the solicitation of informal payments at public sector facilities, including educating patients about the free provision of FP at public facilities in Tanzania and fairly compensating public sector healthcare workers for their labor. Salaries of providers in public sector facilities in Tanzania are typically standardized within specific job “groups,” which, in theory, are based on education and years of experience (though, in practice, promotions can be delayed). In addition, wages may fail to keep pace with inflation and there may be variation across facilities or regions with regard to timely payment of wages (In an email from D. Onyango, MD in January 2022).
There is limited evidence evaluating strategies to reduce informal payments for family planning and reproductive health services, though social accountability approaches have emerged as promising strategies [31, 32]. One social accountability approach, called the Community Score Card, was implemented in Malawi and found to increase client satisfaction, contraceptive use, and service delivery compared to communities who did not receive the intervention, but the intervention’s impact on informal payments was not assessed . Another social accountability intervention was designed to decrease demand for informal payments for maternal health care and implemented in India. The intervention appeared to increase the empowerment and knowledge of participating community members and anecdotal evidence suggested a decrease in demands for informal payments [17, 34].
Though informal payments may be less of a problem in Tanzania than in neighboring countries, progress is still needed to eliminate all informal fees at public sector facilities in Tanzania. Further research should investigate the reasons that informal payments are solicited in public sector facilities, especially government dispensaries, and identify methods for reducing these fees to ensure that the most vulnerable populations have access to the FP services needed to achieve their reproductive goals.
This study uses nationally representative data to investigate informal payments for FP in Tanzania. We use existing data to study an important topic with critical implications for FP access.
Our investigation of informal payments for modern contraceptives was limited by sample size constraints. Because a minority of women reported paying any amount at public or private facilities for implants or injectables, we were not able to assess whether payment amount varied by sociodemographic factors, such as education, age, or wealth. In addition, these existing data do not allow us to assess the proportion of women who were unable to pay informal payments and, therefore, left the facility without a method of contraception. Given evidence suggesting women with fewer resources may be more likely to be asked for informal payments , new indicators are needed to track this equity concern. We are also unable to ascertain whether some FP clients were able to avoid informal payments by insisting on free services or switching to a different provider or different public sector facility. These are important areas for future research.