Looking at the bigger picture: how the wider health financing context affects the implementation of the Tanzanian Community Health Funds

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BACKGROUND

Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.

METHODS

A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.

RESULTS

Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.

CONCLUSIONS

Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy in northern Tanzania

Introduction

Antimicrobial Resistance (AMR) is a growing concern globally, mostly being contributed by a limited understanding of antibiotic utilization as a result of inappropriate acquisition and prescription. Parental awareness is essential in optimizing their usage and preserving the effectiveness of these crucial medications. The current study investigates the usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy ((A)TE) in Northern Tanzania.

Methods

a cross-sectional survey was conducted among parents/caregivers of children who underwent (A)TE in Northern Tanzania. A modified and well-structured questionnaire, which was adapted from a World Health Organization (WHO) questionnaire and used to assess the parents´ knowledge of antibiotics and antibiotic use.

Results

the study included 157 participants. About 54% of the children under the age of 5 years. As of 88% of children had already received antibiotics prior to surgery, 92% of the used antibiotics were prescribed by a clinician, and 5% of parents to used leftovers antibiotics for their children. While 88% of the parents reported adhering to prescriptions, 8% of reported buying the same antibiotic (as prescribed before) without consulting a clinician again when their children are sick.

Conclusion

the use of antibiotics, including broad-spectrum antibiotics, was found to be high in our study group. Parents demonstrate a relatively good understanding of antibiotic usage. It is plausible to speculate that a higher prevalence of non-insured, unemployed, and less educated parents may lead to an increased incidence of misuse and misinterpretation of antibiotics.

Facilitators for and Barriers to the Implementation of Performance Accountability Mechanisms for Quality Improvement in the Delivery of Maternal Health Services in a District Hospital in Pwani Region, Tanzania

Tanzania experiences a burden of maternal mortality and morbidity. Despite the efforts to institute accountability mechanisms, little is known about quality improvement in the delivery of maternal health services. This study aimed at exploring barriers and facilitators to enforcing performance accountability mechanisms for quality improvement in maternal health services. A case study design was used to conduct semi-structured interviews with thirteen key informants. Data were analyzed using thematic analyses. The findings were linked to two main performance accountability mechanisms: maternal and perinatal death reviews (MPDRs) and monitoring and evaluation (M&E). Prioritization of the maternal health agenda by the government and the presence of maternal death review committees were the main facilitators for MPDRs, while negligence, inadequate follow-up, poor record-keeping, and delays were the main barriers facing MPDRs. M&E was facilitated by the availability of health management information systems, day-to-day ward rounds, online ordering of medicines, and the use of biometrics. Non-use of data for decision-making, supervision being performed on an ad hoc basis, and inadequate health workforce were the main barriers to M&E. The findings underscore that barriers to the performance accountability mechanisms are systemic and account for limited effectiveness in the improvement of quality of care.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study

BACKGROUND

Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.

METHODS

An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.

RESULTS

Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.

CONCLUSION

While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

Factors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff

BACKGROUND

Digital interventions for health financing, if implemented at scale, have the potential to improve health system performance by reducing transaction costs and improving data-driven decision-making. However, many interventions never reach sustainability, and evidence on success factors for scale is scarce. The Insurance Management Information System (IMIS) is a digital intervention for health financing, designed to manage an insurance scheme and already implemented on a national scale in Tanzania. A previous study found that the IMIS claim function was poorly adopted by health care workers (HCWs), questioning its potential to enable strategic purchasing and succeed at scale.

OBJECTIVE

This study aimed to understand why the adoption of the IMIS claim function by HCWs remained low in Tanzania and to assess implications for use at scale.

METHODS

We conducted 21 semistructured interviews with HCWs and management staff in 4 districts where IMIS was first implemented. We sampled respondents by using a maximum variation strategy. We used the framework method for data analysis, applying a combination of inductive and deductive coding to organize codes in a socioecological model. Finally, we related emerging themes to a framework for digital health interventions for scale.

RESULTS

Respondents appreciated IMIS's intrinsic software characteristics and technical factors and acknowledged IMIS as a valuable tool to simplify claim management. Human factors, extrinsic ecosystem, and health care ecosystem were considered as barriers to widespread adoption.

CONCLUSIONS

Digital interventions for health financing, such as IMIS, may have the potential for scale if careful consideration is given to the environment in which they are placed. Without a sustainable health financing environment, sufficient infrastructure, and human capacity, they cannot unfold their full potential to improve health financing functions and ultimately contribute to universal health coverage.

Linking the Community Health Fund with Accredited Drug Dispensing Outlets in Tanzania: exploring potentials, pitfalls, and modalities

BACKGROUND

In low- and middle-income countries, too, public-private partnerships in health insurance schemes are crucial for improving access to health services. Problems in the public supply chain of medicines often lead to medicine stock-outs which then negatively influence enrolment in and satisfaction with health insurance schemes. To address this challenge, the government of Tanzania embarked on a redesign of the Community Health Fund (CHF) and established a Prime Vendor System (Jazia PVS). Informal and rural population groups, however, rely heavily on another public-private partnership, the Accredited Drug Dispensing Outlets (ADDOs). This study takes up this public demand and explores the potentials, pitfalls, and modalities for linking the improved CHF (iCHF) with ADDOs.

METHODS

This was a qualitative exploratory study employing different methods of data collection: in-depth interviews, focus group discussions, and document reviews.

RESULTS

Study participants saw a great potential for linking ADDOs with iCHF, following continuous community complaints about medicine stock-out challenges at public health facilities, a situation that also affects the healthcare staff's working environment. The Jazia PVS was said to have improved the situation of medicine availability at public health facilities, although not fully measuring up to the challenge. Study participants thought linking ADDOs with the iCHF would not only improve access to medicine but also increase member enrolment in the scheme. The main pitfalls that may threaten this linkage include the high price of medicines at ADDOs that cannot be accommodated within the iCHF payment model and inadequate digital skills relevant for communication between iCHF and ADDOs. Participants recommended linking ADDOs with the iCHF by piloting the connection with a few ADDOs meeting the selected criteria, while applying similar modalities for linking private retail outlets with the National Health Insurance Fund (NHIF).

CONCLUSIONS

As the government of Tanzania is moving toward the Single National Health Insurance Fund, there is a great opportunity to link the iCHF with ADDOs, building on established connections between the NHIF and ADDOs and the lessons learnt from the Jazia PVS. This study provides insights into the relevance of expanding public-private partnership in health insurance schemes in low- and middle-income countries.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had <ANC4+ visits. The majority of the 366 districts in the three countries had ANC4+ coverage of 50-70%. In Kenya, 13% of districts had < 70% coverage, compared to 10% and 27% of the districts in Uganda and mainland Tanzania, respectively. Only one district in Kenya and ten districts in mainland Tanzania were likely met the target coverage. Six percent, 38%, and 50% of the districts had at most 5000 women with <ANC4+ visits in Kenya, Uganda, and mainland Tanzania, respectively, while districts with > 20,000 women having <ANC4+ visits were 38%, 1% and 1%, respectively. In many districts, ANC4+ coverage and likelihood of attaining the target coverage was lower among the poor, uneducated and those geographically marginalized from healthcare.

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

Factors Associated with the Implementation of an Improved Community Health Fund in the Ubungo Municipality Area, Dar es Salaam Region, Tanzania

Community-based health insurance schemes help households to afford healthcare services. This paper describes healthcare facilities and community factors that are associated with the Improved Community Health Fund (iCHF) scheme in the Ubungo district of Tanzania. A cross-sectional descriptive study was conducted using online questionnaires that were completed by healthcare providers and community members in public-owned healthcare facilities in the Ubungo Municipal Council district of Dar es Salaam, Tanzania, between October and November 2021. The data were analyzed using descriptive statistics and the chi-squared test of association. We found a statistically significant relationship between income level and satisfaction with the iCHF scheme. For community-related factors, income level was statistically significant in the level of involvement in iCHF implementation among local leaders. Further, income level was statistically significant in relation to community behavior/culture toward the iCHF. Occupation was statistically significant in iCHF implementation, iCHF premiums, and iCHF membership size. A statistically significant relationship was also found between income, iCHF membership size, and iCHF premiums. Moreover, people would be willing to pay the required premiums if the quality of the healthcare services under the iCHF scheme improves. Therefore, the government should allocate resources to reduce the challenges that are facing iCHF implementation, such as the preference for a user fee scheme over the iCHF, the issues that are faced by enrollment officers, and inadequate iCHF premiums and membership size.

Health insurance coverage in low-income and middle-income countries: progress made to date and related changes in private and public health expenditure

INTRODUCTION

Several low-income and middle-income countries (LMICs) have implemented health insurance programmes to foster accessibility to healthcare and reduce catastrophic household health expenditure. However, there is little information regarding the population coverage of health insurance schemes in LMICs and on the relationship between coverage and health expenditure. This study used open-access data to assess the level of health insurance coverage in LMICs and its relationship with health expenditure.

METHODS

We searched for health insurance data for all LMICs and combined this with health expenditure data. We used descriptive statistics to explore levels of and trends in health insurance coverage over time. We then used linear regression models to investigate the relationship between health insurance coverage and sources of health expenditure and catastrophic household health expenditure.

RESULTS

We found health insurance data for 100 LMICs and combined this with overall health expenditure data for 99 countries and household health expenditure data for 89 countries. Mean health insurance coverage was 31.1% (range: 0%-98.7%), with wide variations across country-income groups. Average health insurance coverage was 7.9% in low-income countries, 27.3% in lower middle-income countries and 52.5% in upper middle-income countries. We did not find any association between health insurance coverage and health expenditure overall, though coverage was positively associated with public health spending. Additionally, health insurance coverage was not associated with levels of or reductions in catastrophic household health expenditure or impoverishment due to health expenditure.

CONCLUSION

These findings indicate that LMICs continue to have low levels of health insurance coverage and that health insurance may not necessarily reduce household health expenditure. However, the lack of regular estimates of health insurance coverage in LMICs does not allow us to draw solid conclusions on the relationship between health insurance coverage and health expenditure.

Universal health insurance in Africa: a narrative review of the literature on institutional models

Introduction

Several African countries have introduced universal health insurance (UHI) programmes. These programmes aim to extend health insurance to groups that are usually excluded, namely informal workers and the indigent. Countries use different approaches. The purpose of this article is to study their institutional characteristics and their contribution to the achievement of universal health coverage (UHC) goals.

Method

This study is a narrative review. It focused on African countries with a UHI programme for at least 4 years. We identified 16 countries. We then compared how these UHI schemes mobilise, pool and use funds to purchase healthcare. Finally, we synthesised how all these aspects contribute to achieving the main objectives of UHC (access to care and financial protection).

Results

Ninety-two studies were selected. They found that government-run health insurance was the dominant model in Africa and that it produced better results than community-based health insurance (CBHI). They also showed that private health insurance was marginal. In a context with a large informal sector and a substantial number of people with low contributory capacity, the review also confirmed the limitations of contribution-based financing and the need to strengthen tax-based financing. It also showed that high fragmentation and voluntary enrolment, which are considered irreconcilable with universal insurance, characterise most UHI systems in Africa.

Conclusion

Public health insurance is more likely to contribute to the achievement of UHC goals than CBHI, as it ensures better management and promotes the pooling of resources on a larger scale.

Health Insurance Exemptions for Older Ghanaians: Stakeholder Perspectives on Challenges Confronting an Ambitious Policy

The health and wellbeing of older adults have taken center-stage in global policy agendas in recent times. In 2003, Ghana introduced an insurance exemption policy to eliminate financial barriers to healthcare for older adults and other vulnerable population groups. Embedded within the National Health Insurance Scheme (NHIS), this policy ostensibly guarantees free healthcare for older adults at publicly-funded facilities across the country. In this paper, we applied the implementation problem framework to identify gaps in the implementation of the exemptions policy and their impact on the healthcare experiences of older adults. Our data collection involved qualitative interviews with a purposive sample of community-residing older adults, health workers, community leaders, and policymakers. Our thematic data analysis identified resource, substantive, bureaucratic, political, and administrative constraints in the policy implementation process which, in turn, affected quality healthcare delivery. While most of these constraints are general challenges confronting the NHIS, they serve to undermine the intent of the scheme's exemptions policy. In particular, despite the exemptions, older adults continued to pay out-of-pocket for certain categories of treatments and medications, creating as yet financial barriers to healthcare. We present policy recommendations for addressing these implementation challenges, including suggestions to decentralize, depoliticize, and financially liberate the operations of the NHIS.

Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania

Background

Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

Method

An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems’ responsiveness. Qualitative content analysis was used to analyse the data.

Results

Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

Conclusions

The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07144-2.

Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.

The failure of community-based health insurance schemes in Tanzania: opening the black box of the implementation process

BACKGROUND

Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania.

METHODS

A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data.

RESULTS

While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community.

CONCLUSIONS

Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.

Patterns of multimorbidity and their association with hospitalisation: a population-based study of older adults in urban Tanzania

BACKGROUND

while the HIV epidemic remains a considerable challenge in sub-Saharan Africa, a dramatic reduction in the associated mortality has led to a fundamental shift in the public health priorities aimed at tackling multimorbidity. Against the unprecedented level of urbanisation taking place in Tanzania, the burden of multimorbidity and its consequences among ageing adults, in the form of costly inpatient hospitalisation, remain unquantified.

METHODS

we used data from one of Africa's largest urban population cohort, the Dar es Salaam Health and the Demographic Surveillance System, to quantity the extent of multimorbidity (occurrence of 2 ≥ health conditions) and discordant multimorbidity (occurrence of conditions in 2 ≥ domains in mental health, non-communicable and communicable health) among 2,299 adults aged ≥40 years in Dar es Salaam, Tanzania. We fitted logistic regression models to investigate the association between multimorbidity and inpatient hospitalisation.

RESULTS

the prevalence of multimorbidity and discordant multimorbidity were 25.3 and 2.5%, respectively. Although the severe forms of multimorbidity (2.0% with ≥4 health conditions) and discordancy were low, hospitalisation was significantly higher based on the regression analyses. Household food insecurity was the only socio-economic variable that was significantly and consistently associated with a greater hospitalisation.

CONCLUSION

we found an alarmingly high degree of multimorbidity among this ageing urban population where hospitalisation was driven by multimorbidity. As public health resources remain scarce, reducing costly inpatient hospitalisation requires multilevel interventions that address clinical- and structural-level challenges (e.g. food insecurity) to mitigate multimorbidity and promote long-term healthy independent living among older adults in Tanzania.

Impact of social accountability monitoring on health facility performance: Evidence from Tanzania

Social accountability programs are increasingly used to improve the performance of public service providers in low-income settings. Despite their growing popularity, evidence on the effectiveness of social accountability programs remains mixed. In this manuscript, we assess the impact of a social accountability intervention on health facility management exploring quasiexperimental variation in program exposure in Tanzania. We find that the social accountability intervention resulted in a 1.8 SD reduction in drug stockouts relative to the control group, but did not improve facility infrastructure maintenance. The results of this study suggest that social accountability programs may be effective in areas of health service provision that are responsive to changes in provider behavior but may not work in settings where improvements in outcomes are conditional on larger health systems features.

Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study

Introduction

Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania.

Methods

We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data.

Results

A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills.

At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04).

Conclusion

The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10013-y.