The impact of user fees on the quality of health services in Dar-es Salaam public dispensaries: an assessment of the implementation of Bamako initiative in Tanzania.

The 1980s economic recession in many Sub-Saharan Africa countries reduced resources available for the public health sector. Thus in an attempt to raise additional revenue and to provide high quality medical care, Tanzania adopted the user fee policy (cost sharing) in 1993. In 1996, Bamako Initiative was adopted on a pilot scale in Dar es Salaam public dispensaries. Bamako Initiative was launched in 1987 in Bamako, Mali. Since the programme contains two critical components, user fees and improved quality, this study aimed at assessing the impact of user fees on the quality of health care. The survey was conducted in five Dar es Salaam public dispensaries. Quality conceptual framework, and literature on financing options and Bamako Initiative provided the theoretical framework of the study. Expectations were that, user fees will have an impact on the quality of services, if they are spent to meet costs related to quality variables (drugs and equipment, improvement of the infrastructure, incentive for workers and on general cleanliness.) The population included outpatients, health workers, community members and key respondents. The data was collected through a questionnaire, exit interviews, focus group discussions, in depth interviews, non-participant observation and documentary review methods. The gathered data was both qualitative and quantitative. Findings revealed that drugs availability improved, workers' attitude improved and were motivated, satisfaction was high. Moreover high levels of user fees were invested on quality improvements. It was concluded that the impact of user fees on quality depend on the of fees on quality improvements. And that quality assessment should be done at three levels - structure, process and outcome. Recommendations made was that BI programme has potential to improve the quality of health service, hence it should be expanded to other public dispensaries nationwide. With regard to further research, it was suggested that a comparative study, should be conducted to establish cost sharing fee impact on the quality of services offered by referral, regional and district hospitals as compared to Bamako Initiative schemes