Male involvement in the National Health Insurance Fund (NHIF/KfW) prepaid insurance card for pregnant women in Pangani District, Tanzania
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Tani Kassimu, August Kuwawenaruwa, Jitihada Baraka, Fatuma Manzi, – IFAKARA Health Institute, Tanzania
In Tanzania, estimates from 2010 show a maternal mortality ratio (MMR) of 454 maternal deaths per 100,000 live births. For every 1,000 live births in Tanzania, four or five women died of pregnancy-related causes. Reasons for low usage of maternal care are complex, including shortage of resources, long distances to services, high costs and low capacity to provide services.
Gender analyses suggests that maternal mortality is linked to a wide range of factors in women’s lives, including the value placed by women and by their families and communities on women’s health, women’s economic position, their access to education and information, and their capacity to make autonomous decisions. ‘Gender exclusion’, in this case the exclusion of men in planning or implementing interventions, can be a major barrier to achieving improved maternal and child health.
Health insurance, maternal health and gender
In 2010, the National Health Insurance Fund (NHIF) of Tanzania piloted a programme aimed at improving maternal and child health through the provision of insurance coverage to poor families. The pilot programme used the NHIF platform to support and strengthen expansion of social health insurance coverage to the informal sectors by providing free maternal and child health insurance cards named NHIF/KfW prepaid insurance card to poor pregnant women and their newborns in selected regions of Tanga and Mbeya.
Our study sought to understand male involvement in the implementation of a National Health Insurance Fund (NHIF/KfW) for pregnant women in Pangani District, Tanzania. It examined the factors associated with male involvement or lack of involvement in access and use of health services and identify the strategies that can be used to increase male involvement.
Male involvement in the implementation of NHIF/KfW prepaid insurance card
Men were involved in the implementation of NHIF/KfW prepaid insurance card scheme in various ways: during its design; inauguration; registration; and in community sensitization at the village level and health facilities.
Health System Factors: At the health care facilities, women are encouraged to attend with their partners during antenatal visits. This is to ensure they are all tested together for HIV, as well as educated on how to take care of the pregnancy and prepare for delivery. Participants often stated that while men increasingly go with their wives for first ANC and tests for a number of diseases together, they were not always told about the insurance programme while at the facility:
“Things have changed because few years back when you are pregnant you can come alone for health checkups and start ANC services, but nowadays to have a test or even to be registered, you have to come with your husband…” (FGD – women at Pangani Hospital)
“We were told whenever we come to clinic each one has to come with the partner to be tested, I came with him…we were examined but we were not told about the NHIF/KfW insurance programme…” (FGD – women at Mwera Health Centre)
Economic Factors: Maternal and child health care services should be free of charge as per the health care policy. However, in many cases families and partners incur costs related to transport and purchase of supplies. During the implementation of the project, the costs related to the service provision to the women and the family were borne by the programme. This encouraged male involvement because they were sure that they wouldn’t pay for extras at the point of provision:
“Nowadays he has changed, when you fall sick he asks you to go to the facility as he knows it’s free…he cannot say I don’t have to go because we do not have money…if I wouldn’t have gone with him the first day he could not knows…” (FGD – women at Pangani Hospital)
Social Norms: Women had a different views with regard to men’s involvement in the provision of reproductive and child health care services. It is not a usual thing to see a man accompanying the partner as well as carrying a baby to the hospital:
“But just saying a man carrying the baby with happiness….how many are they…you are lucky if you are accompanied by your partner to hospital…in reality I haven’t…“ (FGD – women at Mwera HC)
In addition, a number of women claimed that they did not involve men directly when they went for ANC services and registered for programme because men were at work. This reflects the perception that the role of men in the community is to work and that women should care for the family.
Strategies to increase male involvement
Participants identified strategies to improve male involvement in the implementation of NHIF/KfW prepaid insurance card in Pangani District.
Communication between partners: Communication between partners was one of the ways to increase their men’s involvement. Some of the men who have been involved in the programme are now responsible in taking their children to the health facility for growth monitoring and even when they are sick:
“When you tell a man that I am sick, he will ask you to go to the health facility, you will go and get services …when the child falls sick he will take him to the doctor and when prescribed he will go to find the drugs if they are not available at facilities…” (FGD – women at Mwera HC)
Use of village meetings: In the villages, there are routine meetings every three months. During the meeting, participants discuss various topics and make decisions together for the betterment of the whole community. Health care providers and Community Health Fund (CHF) coordinators can use such meetings to educate/sensitize the community; however, at times doctors are given time to talk at the end of the meetings specifically during the any other business session:
“We suggest that during the village meetings doctors should be given priority to speak as s/he, as they emphasize on health issues men will get to learn, as we usually come with the kids every day to the facility….” (FGD – women at Mwera HC)
Education: Men pointed out that one of the strategies to increase their participation is through education, as they will gain more knowledge about health care services and whatever has been happening in the facilities:
“Your wife goes to clinic while you just go to the farm…. it’s wrong……most of the time we are supposed to accompany our partners and get to know whatever is happening….…there is low awareness….…it’s good whenever people are being sensitized, or as the village chairman calls for a meeting and inform the community whatever is happening…”(FGD – men at Mwera Village)
Programme implementation together with other factors such as health system factors, economic factors and social norms act as facilitators and barriers in terms of male partner involvement in the implementation of the NHIF/KfW insurance programme. Largely these factors were complex and interrelated. Improvement in the health care provision and community sensitization of the importance of male partner involvement in the implementation of maternal and child health care programmes needs to be prioritised in order to improve their participation and mitigate the effect of socio-economic and cultural factors.