Background: To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination
Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during
care-seeking for fever in the Ulanga District in Tanzania.
Methods: We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga
District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in
Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary
depending on ACT availability in their nearest health facility.
Results: Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector,
the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of
respondents who went to the public sector reported incidences of non-compliant behaviour by the attending
health worker (e.g. charging those who were eligible for free service or referring patients to the private sector
despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT
stock-outs were considered to be the result of non-compliant behaviour of others in the health system and
increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding.
Conclusion: System design and governance challenges in the Tanzanian health system have resulted in numerous
ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket
health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase
health worker accountability