Coping strategies for health care financing among informal sector workers in Dar es Salam, Tanzania


  • Bertha Mwinuka Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania; Jomo Kenyatta University of Agriculture and Technology (JKUAT), Juja, Kenya; Centre for Public Health Research, Kenya Medical Research Institute, Nairobi, Kenya
  • Jackline Mosinya Nyaberi Jomo Kenyatta University of Agriculture and Technology (JKUAT), Juja, Kenya
  • Elizabeth Echoka Centre for Public Health Research, Kenya Medical Research Institute, Nairobi, Kenya



Health insurance, Coping methods, Health care financing, Accessibility, Informal sector workers


Background: In low- and middle-income countries (LMICs) health financing systems has been dependent on out-of-pocket payments (OOP). This type of payment is thought to increase income to finance health care but it’s unaffordable to economically disadvantaged persons. Health insurance was introduced in order to reduce catastrophic health expenditure caused by OOP but its implementation to informal sector workers is a challenge. Therefore, this study examines the coping strategies for managing health care costs among informal sector workers in Dar es Salaam, Tanzania.

Methods: This cross-sectional descriptive study was conducted between September and December 2020 to 889 informal sector workers. The study respondents were randomly selected and questionnaire was used to collect data. Chi-square test and multivariate logistic regression were used to analyze data through the use of Statistical Package for Social Sciences (SPSS) version 23.

Results: The findings showed that the mean age of the respondents was 34.8 years (SD±10.4) and majority, (90.1%) of the respondents were uninsured. The methods to carter for medical expenditures were cash payments (p=0.297; 95%CI=0.195-0.452), selling assets (p=0.672, 95%CI=0.507-0.891) and borrowing money (p=0.578, 95%CI=0.412-0.811).

Conclusions: The health care financing methods that the informal sector workers use in order to access health services are effective in reducing short run problems of health care accessibility but it contributes to impoverishment. Designing an affordable insurance scheme with consideration of the social economic aspects of individuals will improve uptake to insurance schemes and hence achievement of the Sustainable Development Goals (SDGs).


Dror DM, Firth LA. The demand for (Micro) Health Insurance in the Informal Sector. Geneva Pap Risk Insur Issues Pract. 2014;39(4):693-711.

Sanogo AN, Fantaye AW, Yaya S. Universal Health Coverage and facilitation of equitable access to care in Africa: A systematic review. Front Public Heal. 2019;7(102):1–10.

Fadlallah R, El-jardali F, Hemadi N, Morsi RZ, Abou C, Samra A, et al. Barriers and facilitators to implementation, uptake and sustainability of community- based health insurance schemes in low- and middle-income countries: a systematic review. 2018;1-18.

Sirag A, Nor NM. Out-of-pocket health expenditure and poverty: Evidence from a dynamic panel threshold analysis. Healthc. 2021;9(5).

Atupele NM, Kamndaya MS, Masangwi SJ. Examining the incidence of catastrophic health expenditures and its determinants using multilevel logistic regression in Malawi. PLoS One. 2021;16(3):1-17.

Makinen M, Waters H, Rauch M, Almagambetova N. Inequalities in health care use and expenditures: Empirical data from. World Heal Organ Bull World Heal Organ. 2000;78(1):55-65.

Wagstaff A. Poverty and health sector inequalities. Bull World Health Organ. 2002;80(2):97-105.

Kutzin J. Health financing for universal coverage and health system performance: concepts and implications for policy. Bull World Health Organ. 2013;91(8):602-11.

Alfers L, Lund F, Moussié R. Approaches to social protection for informal workers: Aligning productivist and human rights-based approaches. 2017;70:67–85.

Koehlmoos TP, John D. Factors affecting uptake of voluntary and community-based health insurance schemes in low- and middle-income countries A systematic review June 2016 Systematic Review. 2016;17.

Garfield R, Orgera K. The Uninsured and the ACA: A Primer - Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act. 2019.

Mtei G, Makawia S, Ally M, Kuwawenaruwa A, Meheus F, Borghi J. Who pays and who benefits from health care ? An assessment of equity in health care financing and benefit distribution in Tanzania. 2012.

Okungu V, Chuma J, Mulupi S, McIntyre D. Extending coverage to informal sector populations in Kenya: Design preferences and implications for financing policy. BMC Health Serv Res. 2018;18(1):1-11.

Simkhada B, Van Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. J Adv Nurs. 2008;61(3):244-60.

Macha J, Harris B, Garshong B, Ataguba JE, Akazili J, Kuwawenaruwa A, et al. Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa. Health Policy Plan. 2012;27(SUPPL.1):46-54.

CAG. Performance Audit Report on The Management of Provision of National Health Insurance Services - Tanzania. 2019;1-82.

Kasahun GG, Gebretekle GB, Hailemichael Y, Woldemariam AA, Fenta TG. Catastrophic healthcare expenditure and coping strategies among patients attending cancer treatment services in Addis Ababa, Ethiopia. BMC Public Health. 2020;20(1):1-10.

Isoto, R. E., Sam, A. G., & Kraybill DS. No TitleUninsured health shocks and agricultural productivity among rural households: The mitigating role of micro-credit. The Journal of Development Studies. J Dev Stud. 2017;53(12):2050-66.

Smith-Lin SBD& M. No TitleThe Role of Savings and Credit in Coping with Idiosyncratic Household Shocks. J Dev Stud. 2018;54((9)):1513-33.

Yilma Z, Mebratie A, Sparrow R, Abebaw D, Dekker M, Alemu G, et al. Coping with shocks in rural Ethiopia. J Dev Stud. 2014;50(7):1009-24.

Sinha T, Ranson MK, Chatterjee M, Acharya A, Mills AJ. Barriers to accessing benefits in a community-based insurance scheme: Lessons learnt from SEWA Insurance, Gujarat. Health Policy Plan. 2006;21(2):132-42.

NBS. Formal Sector Employment and Earnings Survey, 2015 Tanzania Mainland. Natl Bur Stat United Repub Tanzania. 2016;99. Available at: Accessed on 17th December 2022.

Pharm Access. Pharm Access Group: Progress Report 2016. 2017;1-19.

Sedgwick P. Multistage sampling. BMJ. 2015;351.

Hitimana R, Lindholm L, Krantz G, Nzayirambaho M. Cost of antenatal care for the health sector and for households in Rwanda. 2018;1-9.

Binnendijk E, Koren R, Dror DM. Hardship financing of healthcare among rural poor in Orissa, India. BMC Health Serv Res. 2012;12(1).

Nshakira-Rukundo E, Mussa EC, Cho MJ. Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural southwestern Uganda. PLoS One. 2021;16:1-13.

Ridzuan F, Wan Zainon WMN. A review on data cleansing methods for big data. Procedia Comput Sci. 2019;161:731-8.

Adewole DA, Akanbi SA, Osungbade KO, Bello S. Expanding health insurance scheme in the informal sector in Nigeria: awareness as a potential demand-side tool. Pan Afr Med J. 2017;27:52.

Dror DM, Shahed Hossain SA, Majumdar A, Koehlmoos TLP, John D, Panda PK. What factors affect voluntary uptake of community-based health insurance schemes in low- and middle-income countries? A systematic review and meta-analysis. PLoS One. 2016;11(8).

Hailemichael Y, Hanlon C, Tirfessa K, Docrat S, Alem A, Medhin G, et al. Catastrophic health expenditure and impoverishment in households of persons with depression: A cross-sectional, comparative study in rural Ethiopia. BMC Public Health. 2019;19(1):1-13.

Gnawali DP, Pokhrel S, Sié A, Sanon M, De Allegri M, Souares A, et al. The effect of community-based health insurance on the utilization of modern health care services: Evidence from Burkina Faso. Health Policy (New York). 2009;90(2–3):214-22.

Parmar D, De Allegri M, Savadogo G, Sauerborn R. Do community-based health insurance schemes fulfil the promise of equity? A study from Burkina Faso. Health Policy Plan. 2014;29(1):76-84.

Umeh CA, Feeley FG. Inequitable access to health care by the poor in community-based health insurance programs: A review of studies from low-and middle-income countries. Glob Heal Sci Pract 2017;5(2):299-314.

Obembe TA, Bankole OT, Abbas G, Ajayi IOO. Healthcare service payment methods and coping strategies of nomads and labor migrants in Oyo State, Nigeria. Am J Trop Med Hyg. 2020;102(5):1022-9.

Akazili J, Chatio S, Ataguba JEO, Agorinya I, Kanmiki EW, Sankoh O, et al. Informal workers’ access to health care services: Findings from a qualitative study in the Kassena-Nankana districts of Northern Ghana. BMC Int Health Hum Rights. 2018;18(1):1-9.

Kabir A, Datta R, Raza SH, Maitrot MRL. Health shocks, care-seeking behaviour and coping strategies of extreme poor households in Bangladesh’s Chittagong Hill tracts. BMC Public Health. 2019;19(1):1-12.

Tahsina T, Ali NB, Siddique AB, Ahmed S, Rahman M, Islam S, et al. Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh. PLoS One. 2018;13(5):1–17.

Care H, Scheme KE, Alatinga KA. The Impact of Mutual Health Insurance Scheme on Access and Quality of Health Care in Northern Ghana : The Case of Kassena-Nankana East Scheme. 2011.

Adewole DA, Akanbi SA, Osungbade KO, Bello S. Expanding health insurance scheme in the informal sector in Nigeria: awareness as a potential demand-side tool. Pan Afr Med J. 2017;27:52.




How to Cite

Mwinuka, B., Nyaberi, J. M., & Echoka, E. (2023). Coping strategies for health care financing among informal sector workers in Dar es Salam, Tanzania . International Journal Of Community Medicine And Public Health, 10(6), 2024–2030.



Original Research Articles