Who's Raising the Bar? A Comparative Analysis of Healthcare Quality in Rural and Urban Primary Care Settings in Tanzania

Who's Raising the Bar? 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A Comparative Analysis of Healthcare Quality in Rural and Urban Primary Care Settings in Tanzania Syabo M. Mwaisengela, Chrisogone J. German, Patricia A. Materu, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6466987/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Rural-urban disparities in quality of care and healthcare services utilization is a significant issue in both developed and developing countries. This leads to inequitable access to quality healthcare, poorer health outcomes and poor performance of a health system. Objective This study is dedicated to unveiling the prevailing variation in quality of healthcare across rural and urban Primary Healthcare (PHC) settings in Tanzania. Methods This is a quantitative secondary data analysis using the Star Rating Assessment (SRA) data collected in the fiscal year 2017/2018. Compliance with HCQS was measured by considering service delivery areas of SRA Tool. With the aid of Stata 18, we used Chi Square and Proportion Z tests for comparative analyses in regard to facility level and facility ownership. Spatial variation by region were visualized with the aid of QGIS 3.8 Firenze. Results This study involved 5,933 PHCs, majority of which were rural located (78.3%), public owned (77.2%) and dispensaries (87.7%). On average, 46.9% (95% C.I 32.9% − 35.6%) of Urban health facilities, complied with HCQS compared to 34.3% (95% C.I 32.9% − 35.6%) of rural health facilities. This difference is statistically significant, indicating that urban health facilities are significantly more likely to comply with quality indicators compared to their rural counterparts (z=-8.3, p < 0.001). A disaggregated analysis by facility level and ownership showed higher variation in compliance with HCQS among rural compared to urban health facilities. Conclusions This study demonstrates prevailing disparities in compliance with HCQS between Urban and Rural health facilities. To ensure equitable accessibility to quality healthcare services, this significant gap should be worked on including equitable allocation of HRH, improving infrastructure and the availability of health commodities in rural settings. Urban Rural Primary Healthcare Facilities Compliance Quality Standards Star Rating Assessment Tanzania Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Worldwide, rural populations are recognized for being exposed to increased health challenges due to their living and working environment, socioeconomic status, and access to health services ( 1 ). Michael Lipton’s 1977 Burban bias has cumulatively assumed urban areas are less vulnerable to development and interventions needed to target rural areas, if there remains a class conflict between the rural and urban populations resulting in the systematic under-development of rural areas and thus the persistence of poverty ( 2 ). Without transformative policy changes to overhaul the centralized colonial healthcare system, the significant rural-urban divide in healthcare resources persists in Tanzania. The hospitals and dispensaries established during the colonial era were unevenly distributed across regions, creating inequities in Mental Health Care (MHC) ( 3 – 5 ). Access to hospital-based MHC was restricted to women living in areas considered important to colonialists, with a greater emphasis on providing urban healthcare services rather than rural areas ( 4 ). This historical legacy reverberates through a rural-urban divide in healthcare, marked by the disproportionate distribution of mental health care in urban areas ( 3 ). Health infrastructures in rural areas are likely to have inadequate drug supplies ( 6 ), a lack of maternal health experts, and geographic isolation ( 7 , 8 ). The unequal distribution of healthcare facilities between rural and urban areas ( 9 , 10 ) and the pyramidal healthcare system favor urban residents more than rural residents in Tanzania ( 11 ). In Tanzania, health services are delivered through a decentralized system that broadly falls into three functional levels namely Local Government Authority (LGA) which is the primary level, regional (secondary level), and referral hospital (tertiary level) ( 12 , 13 ). The LGA level provides Primary Healthcare (PHC) services through dispensaries and health centers. Dispensary serves as first point of contact of patient to health system while offering basic health services. Health center acts as the referral level for the dispensary and provides a slightly broader range of services, including inpatient care and level 1 hospitals as the top level serving as a referral center that includes council hospitals or council designated hospital (CDH). In councils where there is no government hospital, a service agreement is signed between government and a hospital run by a faith-based organization (referred as CDH) ( 14 , 15 ). Previously, there was no reliable nationwide data source gathering information on the quality of healthcare in rural and urban settings. However, in 2014, the Government of Tanzania introduced the implementation of the “Big Results Now” initiative in the health sector, which resulted in the design of the Star Rating Assessment (SRA) as one of its interventions aiming at improving the performance of PHC facilities ( 16 ). In the financial year 2015/2016, Tanzania Mainland conducted a countrywide assessment of all PHC facilities and assigned a star ranging from 0 to 5 stars based on the status of quality services. In 2017/2018, a countrywide re-assessment was done ( 17 – 19 ). The Star Rating Assessment Tool (SRT) covered twelve ( 12 ) service areas, namely Legality (Licensing and Certification), Health Facility Management, Use of Facility Data for Planning and Service Improvement, Staff Performance Assessment, Organization of Services, Handling Emergencies and Referral, Client Focus, Social Accountability, Facility Infrastructure, Infection Prevention and Control (IPC), Clinical Services, and Clinical Support Services. Most of studies have focused rural and urban disparities in Health System Performance, patient satisfaction, services utilization, Health Information access and quality assessment on regional differences of patient satisfaction mostly in developed countries ( 20 – 24 ). However little research has been conducted on disparities in quality of healthcare between rural and Urban healthcare facilities in limited resources settings like Tanzania. This study is therefore dedicated to unveiling the prevailing variation across rural and urban settings in Tanzania as evidenced by the second-round Star Rating Assessment. This is the most recent assessment that was comprehensive enough to cover all twenty-six regions of the Tanzania mainland and was conducted in fiscal year 2017/2018. Methods Study design This study employed the analytical cross-sectional design to ascertain the rural and urban differences in compliance with Healthcare Quality Standards (HCQS) that signifies Quality of Healthcare among Primary Healthcare Facilities (PHCFs) using data collected during the re-assessment SRA conducted during the fiscal year 2017/2018. Setting Tanzania is a lower-middle-income country in East Africa, with a surface area estimated at 945,087 km 2 . According to the population and housing census (2022), Tanzania has a total population of 61,741,120, with 40,196,497 (65,1%) residing in urban areas whereas 21,544,623 (34.9) in rural ( 25 ). Administratively, Tanzania mainland comprises 26 regions (Fig. 1 ), 139 Districts, 184 Councils, 570 Divisions, 3956 Wards, and 12319 villages ( 25 ). Primary health facilities are categorized into three levels: district hospitals, health centers and dispensaries. As of 16th July 2023, there is a total of 6519 PHCs, of which 5582 (85.6%) are dispensaries, 767 (11.8%) are health centers, and 170 (2.6%) are district hospitals ( 26 ). Study population This paper aims to reveal the rural and urban differences in compliance with healthcare quality standards in Tanzania, located in the eastern part of Africa, which has 26 administrative regions (Fig. 1 ). The second assessment was conducted in the financial year 2017/2018, during which a total of 5933 PHC facilities, accounting for 81.4% of the visited health facilities, were extracted for analysis. 18.6% of the visited facilities were excluded due to missing values (> 5%) for most indicators necessary for compliance with healthcare quality standards ( 27 ). Data Source As far as this study is concerned, data were sourced from Star Rating Assessment (SRA), which is an initiative belonging to the BRN workstream, namely Performance Management of Health Facilities. Data were collected from Star Rating Tools (SRT) for Dispensaries, Health Centers and District Hospitals. Regardless of the level of service, the SRT is broken down into four domains: Domain A is for facility management and staff performance with service areas 1, 2, 3, and 4, namely legality, facility management, Health Management Information System, and staff performance and appraisal system respectively. Domain B is for service charters and social accountability with service areas 5, 6, 7, and 8, namely organization of services, emergency and referral system, client focus, and social accountability, respectively. Domain C is for safe and conducive facilities with service areas 9 and 10 namely facility infrastructure and Infection Prevention and Control (IPC) respectively and Domain D is for Quality of Care and Services with service areas 10 and 11 namely clinical services and clinical support services respectively. Within service areas, there are several indicators within which verification criteria denote quality standards that are to be met by a health facility ( 14 ). To date, three SRAs have been conducted where a baseline assessment was conducted in the fiscal year 2015/2016, the second assessment (reassessment) was conducted in the fiscal year 2017/2018, and the most recent assessment (third assessment) was conducted in the fiscal year 2021/2022 for only ten ( 10 ) regions. Therefore, the second assessment is the most recent assessment that was comprehensive enough to produce representative findings of which all twenty-six ( 26 ) regions were visited. Variables As Table 1 shows, in this study, the dependent variable is compliance with HCQS that served as an outcome variable for all analyses conducted. The main independent variable was facility geographical location along with other variables (facility level and facility ownership) that are evidenced to be significant in as far as health systems performance and performance of quality indicators are concerned ( 28 – 34 ). These variables were used for comparative analysis of compliance with HCQS among rural and urban located PHC facilities. Table 1 Study Variables SN Variable Name Variable Type Variable Definition 1 Compliance with HCQS Dependent Health facility compliance with HCQS is treated as categorical scores where aggregate scores encompassing six service areas namely organization of services, handling of emergencies and referrals, Infrastructure, Infection Prevention and Control, Clinical services and clinical support services. The Yes, Partial and No Responses to compliance with HCQS verification criteria for the aforementioned service areas were assigned 1,0.5 and 0 scores respectively. In this regard, sum of scores were considered as numerator while total number of compliances with HCQS verification criteria (Assuming that all criteria scored 1) as denominator and hence yielded final scores that ranged between 0 (0%) and 1 (100%). These scores were then dichotomized into “Compliance” if scores were greater than or equal to 0.6 (60%) and “ Non-Compliance” if scores were less than 0.6 (60%). 5 Facility location Independent This refers to geographical location of health facilities as defined by Tanzania National Human Settlement policy (2000) i.e. Urban or Rural located ( 35 ). 3 Facility Level Independent This refers to facility level of services entailing District Hospital, Health Center or Dispensary the former being of higher level than the latter ( 15 ). 4 Facility ownership Independent This refers to facility ownership entailing Public or Private owned health facilities. Data management Data were extracted from the SRA database for each health facility. They were transposed and manipulated in Microsoft Excel to create a single dataset. The dataset was imported into Stata IC 18 for descriptive and inferential statistical analysis. Data analysis Data were geospatially visualized using Quantum Geographical Information Software (QGIS) 3.16 Hannover. A comparative analysis was conducted regionwide regarding facility characteristics, including facility level, location, and ownership. Proportion Z tests (one-sample and two-sample) and chi-square tests were used to compare proportions. In this study, analyses were performed to determine differences in compliance with HCQS among health facilities located in rural and urban areas concerning three performance categories: less than 40%, between 40% and less than 60%, and 60% and above, which were assigned as poor, good progress, and good coverage, respectively. Comparative analysis was made for all 26 Tanzanian Mainland regions, by health facility level and facility ownership. The spatial regional variation documentation highlights the need to understand the broader subnational systems and context which may influence culture and effectiveness at the facility level and a health system as whole ( 36 ). Inclusion criteria Schafer (2016) suggests that, missing percentages of ≤ 5% are thought to be trivial otherwise, the results will be biased ( 27 ). Therefore, the criteria for inclusion were all health facilities (Level 1 Hospitals, Health Centers, and dispensaries) visited during the second SRA (2017/2018), with less than 5% missing or invalid verification criteria necessary for estimating compliance with HCQS scores i.e. outcome variable of the study. Exclusion criteria The exclusion criteria were all health facilities with more than 5% missing verification criteria that were to be used to estimate the compliance with HCQS scores. Results Characteristics of health facilities involved in the analysis This analysis involved a total of 5,933 PHC facilities, the majority of which were dispensaries (87.7%), rural located (78.3%), and public-owned (77.2%) (Table 2 ). Table 2 Characteristics of health facilities involved in the analysis Variable N (%) Facility Type Hospitals 80 (1.4) Health Centres 652 (11.0) Dispensaries 5201 (87.7) Facility Location Urban 1285 (21.7) Rural 4648 (78.3) Facility Ownership Public 4578 (77.2) Private 1355 (22.8) Rural vs urban health facilities and quality of healthcare A two-sample proportional Z test revealed that 46.9% (95% C.I 32.9% − 35.6%) of urban health facilities complied with HCQS. In contrast, 34.3% (95% C.I 32.9% − 35.6%) of rural health facilities met HCQS standards (Fig. 2 ). This difference is statistically significant, indicating that urban health facilities are significantly more likely to comply with quality indicators compared to their rural counterparts (z=-8.3, p < 0.001). Rural vs urban health facilities and quality of care by facility ownership As visualized in Fig. 3 , a two-sample proportional Z test revealed that among public health facilities, 35.3% (95% C.I 33.8% − 36.8%) of rural facilities complied with HCQS, while 51.8% (95% C.I 48.0% − 55.5%) of urban facilities complied with HCQS (z = -8.23, p < 0.001). Conversely, among private health facilities, 28.9% (95% C.I 25.7% − 32.1%) of rural facilities complied with HCQS, while 41.2% (95% C.I 37.2.0% − 45.2%) of urban facilities complied with HCQS (z = -4.75, p < 0.001). This indicates that, a more significant difference in compliance with HCQS between urban and rural located health facilities is observed when health facilities are public owned. Rural vs urban health facilities and quality of care by facility level As Fig. 4 shows, among rural health facilities, an analysis showed a significant difference in compliance with HCQS among dispensaries, health centers and level 1 hospitals ( \(\:{Chi}^{2}\) =43.83, p < 0.001). On the other hand, among urban-located health facilities, an analysis showed a non-significant difference in compliance with HCQS among dispensaries, health centers and level 1 hospitals ( \(\:{Chi}^{2}\) =0.85, p < 0.651). This indicates that dispensaries, health centers and level 1 hospitals differ more significantly in terms of the quality of healthcare where health facilities are rurally located. A two-sample proportional Z test revealed that among hospitals, 13.6% (95% C.I 4.8% − 22.3%) of rural health facilities complied with HCQS, while 38.1% (95% C.I 17.3% − 58.9%) of urban health facilities complied with HCQS (z = -2.41, p < 0.001). Among health centers, 22.5% (95% C.I 18.7% − 26.4%) of rural health facilities complied with HCQS, while 45.6% (95% C.I 38.6% − 52.6%) of urban health facilities complied with HCQS (z = -5.92, p < 0.001). Among dispensaries, 35.8% (95% C.I 34.4% − 37.3%) of rural health facilities complied with HCQS, while 47.3% (95% C.I 44.3% − 50.3%) of urban health facilities complied with HCQS (z = -6.87, p < 0.001). This indicates that, a more significant difference in compliance with HCQS between urban and rural located health facilities is observed when health facilities are of lower level (Dispensaries in this case). Rural vs urban health facilities and regional variations in compliance with HCQS Among rural health facilities, the analysis showed a significant difference in health facilities that complied with HCQS in all twenty-six regions ( \(\:{Chi}^{2}\) =596.8, p < 0.001). On the other hand, among urban-located health facilities, a significant difference in health facilities complied with HCQS among all regions was observed ( \(\:{Chi}^{2}\) =147.8, p < 0.001). This indicates that regionwide, health facilities differ more significantly when they are rurally located (Fig. 5 ). The analysis shows that among rural-located health facilities, only the Geita region showed satisfactory coverage. Eight ( 8 ) regions showed good progress, while the remaining seventeen ( 17 ) regions had poor coverage (less than 40%). On the other hand, among urban-located health facilities, six ( 6 ) regions, namely Kagera, Shinyanga, Simiyu, Arusha, Kilimanjaro, and Dodoma, had satisfactory percentage coverage. Eight ( 8 ) regions showed good progress, while the remaining twelve ( 12 ) regions showed poor coverage. Discussion The findings of this study reveal substantial disparities in healthcare quality between rural and urban health facilities. Urban healthcare facilities generally have better-equipped hospitals, advanced medical technologies, and a higher density of skilled healthcare professionals compared to rural areas ( 37 – 39 ). These advantages result in enhanced diagnostic capabilities, shorter waiting times, and improved health outcomes, reinforcing conclusions drawn from previous studies ( 40 – 42 ). Conversely, rural healthcare facilities often face significant shortages of medical equipment, essential medicines, and trained personnel, which hinder the delivery of quality healthcare services ( 43 , 44 ). Furthermore, findings indicate that healthcare quality varies significantly between public and private health facilities in both rural and urban areas. Private urban facilities typically demonstrate higher quality care due to better financing mechanisms, improved infrastructure, and a greater concentration of skilled personnel, which aligns with existing literature on the benefits of private sector healthcare ( 45 , 46 ) 40). Conversely, public rural facilities often encounter resource constraints that impede service quality, including frequent drug shortages and understaffing ( 44 ). These findings underscore the necessity for targeted resource allocation strategies to enhance the quality of care in public rural settings while leveraging efficiencies from the private sector to improve service delivery in underserved regions. Findings show that variations in healthcare quality are also observed when comparing different levels of health facilities. Higher-level facilities (District hospitals in this case) provide superior quality care due to advanced medical technologies, specialized healthcare services, and better funding structures (47,48). Conversely, lower-level primary health facilities often struggle with inadequate medical supplies, fewer specialized healthcare providers, and infrastructural limitations ( 46 , 49 ). The disparity in quality across facility levels highlights the need for investment in lower-level health facilities, particularly in rural regions, to ensure that basic healthcare services meet quality standards and are accessible to all populations. Conclusion and Recommendations This study reveals significant differences in healthcare quality between rural and urban settings, likely due to urban areas having better infrastructure, sustainable financing, and governance structures. Addressing these disparities requires comprehensive policy interventions, including improving infrastructure and the availability of health commodities, targeted subsidies for rural areas and enhanced insurance coverage to increase revenue collection for rural healthcare services, strengthening governance and facility autonomy in rural areas can also enhance efficiency and service delivery, as well as establishing incentive programs for the retention of healthcare professionals in rural settings. By implementing these measures, healthcare quality in rural areas can be improved leading to a more equitable and resilient healthcare system, embodying the "Health sector that ensures equitable, accessible, and quality health services for all Tanzanians." vision of Health Sector Strategic Plan V (2021–2026) given that, over two-thirds of Tanzanians reside in rural areas rely on such health facilities for accessing healthcare services ( 10 ). Declarations Authors Contributions SMM analysed data and developed an initial draft, PAM and CJG cleaned and manipulated raw data into structured dataset, ESE, PL, LDM and PL had a critical role of reviewing the manuscript. All authors contributed to the critical review of interpretation of results, discussion of findings, conclusion and recommendations. Funding: No official funding was received by the authors for the study. Data manipulation and analysis was conducted as a part of usual responsibilities. Most of authors are from Health Quality Assurance Unit which is responsible in implementing SRA and hence obliged to disseminate evaluation results through publications. Data Availability: Upon request from the corresponding author, the dataset used in the current study is available Competing interests: The authors declared no conflict of interest. However, during the SRA of PHCs that yielded these data, Eliudi S. Eliakimu, Joseph C. Hokororo, Chrisogone J. German, and Talhiya A. Yahya worked with the Health Quality Assurance Division (now called the Health Quality Assurance Unit) and were responsible for implementing SRA and Quality Improvement Plans (QIPs) follow-up. Ethical Approval: This study did not involve human subjects; hence, for this type of study, formal consent is not required. However, prior permission was sought from the Ministry of Health before using data. Ethical clearance is not necessary for this type of a study because data were collected in the course of implementing government initiative (Star Rating Assessment) and hence this analysis aims at giving feedback after its successful implementation. Disclaimers: The authors declare that the views expressed in this manuscript are their own and not an official position of any institution or funder for personal interests. Acknowledgements: The authors would like to acknowledge the Ministry of Health for granting permission to use the SRA data. Furtherly, our sincere gratitude goes to key partners in the implementation of the SRA that include directorates and units of Ministry of Health embracing Health Quality Assurance Unit, Curative Services Division, Preventive Services Division and the Directorate of Health, Social Welfare and Nutrition Services of the President’s Office – Regional Administration and Local Government (PO-RALG), development partners including the World Bank, Centres for Disease Control and Prevention, Danish International Development Agency, The World Health Organization, Association of Private Health Facilities in Tanzania, and Christian Social Services Commission. Nevertheless, Regional Secretariats, Local Government Authorities and Healthcare Workers in visited PHC Facilities in all 26 regions are highly acknowledged for their cooperation in the implementation of SRA. References Brîndușe LA, Eclemea I, Neculau AE, Păunescu BA, Bratu EC, Cucu MA. Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey. BMC Health Serv Res. 2024;24(1):1341. Lipton M. Why Poor People Stay Poor: Urban Bias in World Development. London: Temple Smith; 1977. Shija AE, Msovela J, Mboera LEG. Maternal health in fifty years of Tanzania independence: Challenges and opportunities of reducing maternal mortality. Volume 13. Tanzania Journal of Health Research. National Institute for Medical Research; 2011. pp. 1–15. Turshen M. The Impact of Colonialism on Health and Health Services in Tanzania. International Journal of Social Determinants of Health and Health Services [Internet]. 1977 [cited 2024 Sep 25]; Available from: https://journals.sagepub.com/doi/ 10.2190/L9G4-KJVK-AW7A-Q9JD Burton A. Urbanization in East Africa, circa 900–2010 CE. Volume 1. Oxford: Oxford University Press; 2017. Levira F, Todd G. Urban Health in Tanzania: Questioning the Urban Advantage. J Urb Health. 2017;94(3):437–49. Manzi F, Schellenberg JA, Hutton G, Wyss K, Mbuya C, Shirima K et al. Human resources for health care delivery in Tanzania: A multifaceted problem. Hum Resour Health. 2012;10. Sirili N, Frumence G, Kiwara A, Mwangu M, Anaeli A, Nyamhanga T et al. Retention of medical doctors at the district level: A qualitative study of experiences from Tanzania. BMC Health Serv Res. 2018;18(1). Tsawe M, Moto A, Netshivhera T, Ralesego L, Nyathi C, Susuman AS. Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland. Int J Equity Health. 2015;14(1). Boex J, Fuller L, Malik A. Decentralized Local Health Services in Tanzania: Are Health Resources Reaching Primary Health Facilities, or Are They Getting Stuck at the District Level? 2015 Apr. UNICEF. Tanzania Maternal and Newborn Health Disparities. Dar Es Salaam; 2016. Primary Healthcare System (PRIMASYS): Comprehensive case study from United Republic of Tanzania [Internet]. Geneva. 2017. Available from: http://apps.who.int/bookorders Kapologwe NA, Meara JG, Kengia JT, Sonda Y, Gwajima D, Alidina S et al. Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: A strategy towards achieving universal health coverage in Tanzania. BMC Health Serv Res. 2020;20(1). Galukande M, von Schreeb J, Wladis A, Mbembati N, de Miranda H, Kruk ME, et al. Essential surgery at the district hospital: A retrospective descriptive analysis in three african countries. PLoS Med. 2010;7(3):1–10. MoHSW. Primary Health Services Development Programme (PHSDP.) 2007–2017 [Internet]. Dar Es Salaam; 2007 Aug [cited 2022 Aug 6]. Available from: http://www.frankshospitalworkshop.com/organisation/management_documents/Tanzania-Primary%20Health%20Services%20Development%20Programme%202007-2017%20-%20MoH%20Tanzania.pdf URT. National Key Result Area healthcare. 2015/16–2017/18, Big Results Now roadmap [Internet]. Dar Es Salaam; 2015 [cited 2024 Sep 23]. Available from: https://pemandu.org/wp-content/uploads/2023/05/TZ-BRN-Healthcare-NKRA-Rev-11-web_English.pdf Gage AD, Yahya T, Kruk ME, Eliakimu E, Mohamed M, Shamba D, et al. Assessment of health facility quality improvements, united republic of Tanzania. Bull World Health Organ. 2020;98(12):849–A858. Yahya T, Mohamed M. Raising a mirror to quality of care in Tanzania: the five-star assessment. The Lancet Global Health. Volume 6. Elsevier Ltd; 2018. pp. e1155–7. German CJ, Mollel HA, Anasel MG, Yahya TA, Hokororo JC, Bahegwa RP, et al. Assessment of Implementation of the Star Rating System in Primary Health Facilities: Experience from Tanzania. J Service Sci Manage. 2023;16(03):249–65. Yaya S, Bishwajit G, Ekholuenetale M, Shah V, Kadio B, Udenigwe O. Urban-rural difference in satisfaction with primary healthcare services in Ghana. BMC Health Serv Res. 2017;17(1). Spasojevic N, Vasilj I, Hrabac B, Celik D. Rural - Urban Differences in Health Care Quality Assessment. Materia Socio Med. 2015;27(6):409. Qin VM, McPake B, Raban MZ, Cowling TE, Alshamsan R, Chia KS et al. Rural and urban differences in health system performance among older Chinese adults: Cross-sectional analysis of a national sample. BMC Health Serv Res. 2020;20(1). Chen X, Orom H, Hay JL, Waters EA, Schofield E, Li Y, et al. Differences in Rural and Urban Health Information Access and Use. J Rural Health. 2019;35(3):405–17. Ying M, Wang S, Bai C, Li Y. Rural-urban differences in health outcomes, healthcare use, and expenditures among older adults under universal health insurance in China. PLoS ONE. 2020;15(10 October). NBS. Administrative units population distribution report [Internet]. Dodoma. 2022 [cited 2023 Jul 16]. Available from: https://www.nbs.go.tz/index.php/en/census-surveys/population-and-housing-census/852-2022-population-and-housing-census-administrative-units-population-distribution-and-age-sex-reports MoH. HFR web portal [Internet]. 2024 [cited 2023 Jul 16]. Available from: https://hfrs.moh.go.tz/web/index.php Schafer J. Multiple imputation: a primer. Stat Methods Med Res. 2016;8(1):3–15. Kinyenje ES, Yahya TA, Hokororo JC, Eliakimu ES, Mohamed MA, Degeh MM et al. Social accountability in primary health care facilities in Tanzania: Results from Star Rating Assessment. 2022; Available from: https://doi.org/10.1371/journal.pone.0268405 German CC, Kinyenje ES, Yahya TA, Hokororo JC, Nungu S, Mohamed MA et al. The Use of Data for Planning and Services Improvement in Tanzanian Primary Healthcare Facilities: Experience from Star Rating Assessment. Journal of Service Science and Management [Internet]. 2023;16(02):144–60. Available from: https://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162010 Mwaisengela SM, Hokororo JC, German CJ, Kinyenje ES, Bahegwa RP, Yahya TA et al. Functionality of Primary Health Facilities Management Teams: Learning from 2017/2018’s Tanzania Star Rating Assessment. Journal of Service Science and Management [Internet]. 2023;16(02):94–109. Available from: https://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162007 Arsenault-Lapierre G, Bui TX, Le Berre M, Bergman H, Vedel I. Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review. BMC Health Serv Res. 2023;23(1). Van Der Hoeven M, Kruger A, Greeff M. Differences in health care seeking behaviour between rural and urban communities in South Africa [Internet]. 2012. Available from: http://www.equityhealthj.com/content/11/1/31 Oladipo JA. Utilization of health care services in rural and urban areas: A determinant factor in planning and managing health care delivery systems. Afr Health Sci. 2014;14(2):322–33. Quigley DD, Chastain AM, Kang JA, Bronstein D, Dick AW, Stone PW et al. Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States. Vol. 23, Journal of the American Medical Directors Association. Elsevier Inc.; 2022. p. 1653.e1-1653.e13. URT. National Human Settlements Development Policy. Dar es Salaam; 2000 Jan. Macarayan EK, Ratcliffe HL, Otupiri E, Hirschhorn LR, Miller K, Lipsitz SR et al. Facility management associated with improved primary health care outcomes in Ghana. PLoS ONE. 2019;14(7). Dussault G, Franceschini MC. Not enough there, too many here: Understanding geographical imbalances in the distribution of the health workforce. Volume 4. Human Resources for Health; 2006. Shemdoe A, Mbaruku G, Dillip A, Bradley S, William JJ, Wason D et al. Explaining retention of healthcare workers in Tanzania: Moving on, coming to look, see and go, or stay? Hum Resour Health. 2016;14(1). Araujo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries [Internet]. Washington; 2013 [cited 2025 Apr 2]. Available from: https://www.worldbank.org/en/topic/health/publication/how-to-recruit-retain-health-workers-in-rural-remote-areas-in-developing-countries McCulley EM, Mullachery PH, Ortigoza AF, Rodríguez DA, Diez Roux AV, Bilal U. Urban Scaling of Health Outcomes: a Scoping Review. Journal of Urban Health. Volume 99. Springer; 2022. pp. 409–26. Langa N, Bhatta T, Erratum. The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization(PLoS ONE (2020) 15:11 (e0241746) 10.1371/journal.pone.0241746 . Vol. 18, PLoS ONE. Public Library of Science; 2023. Song J, Liu L, Miao H, Xia Y, Li D, Yang J et al. Urban health advantage and penalty in aging populations: a comparative study across major megacities in China. Lancet Reg Health West Pac. 2024;48. Brîndușe LA, Eclemea I, Neculau AE, Păunescu BA, Bratu EC, Cucu MA. Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey. BMC Health Serv Res. 2024;24(1):1341. Rahman T, Gasbarro D, Alam K, Alam K. Rural–urban disparities in household catastrophic health expenditure in Bangladesh: a multivariate decomposition analysis. Int J Equity Health. 2024;23(1). Beatty K, Heffernan M, Hale N, Meit M. Funding and service delivery in rural and urban local us health departments in 2010 and 2016. Am J Public Health. 2020;110(9):1293–9. Lewis TP, McConnell M, Aryal A, Irimu G, Mehata S, Mrisho M, et al. Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis. Lancet Glob Health. 2023;11(6):e862–70. Liu Y, Zhong L, Yuan S, van de Klundert J. Why patients prefer high-level healthcare facilities: A qualitative study using focus groups in rural and urban China. BMJ Glob Health. 2018;3(5). Osei Afriyie D, Loo PS, Kuwawenaruwa A, Kassimu T, Fink G, Tediosi F et al. Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care. Soc Sci Med. 2024;347. Bintabara D, Mpondo BCT. Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey. PLoS ONE. 2018;13(2). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6466987","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":444088208,"identity":"a88fa3bf-3846-4bb8-81ad-7a46726b1378","order_by":0,"name":"Syabo M. Mwaisengela","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYHACNgaGCgkexvYGINvAglgtZ2zkmHsOgLRIEKmFsS3NmH1GAohDhBb5GcnPHnxgO5zYO/P51Q0/CiQY+Nu7E/BqMbiRZm44g+dw4szZOWU3e4AOkzhzdgN+LRIJZtI8EocTN87OSbvBA9RiIJGLX4v8jPRv0jwGhxP33zyTdvMPMVoYbuQAbUlIM2acwX7sNlG2GJx5U24444CNHGNPDtttGQMJHoJ+kW9P3/bg4z9QVB5/dvPNHxs5/vZeAg4TSICxeAzAJH7lIMB/AMZif0BY9SgYBaNgFIxIAABu9kr1VN2ITgAAAABJRU5ErkJggg==","orcid":"","institution":"Mzumbe University","correspondingAuthor":true,"prefix":"","firstName":"Syabo","middleName":"M.","lastName":"Mwaisengela","suffix":""},{"id":444088211,"identity":"ebdf2dbc-24a0-4098-91ec-1d877f32ba7a","order_by":1,"name":"Chrisogone J. German","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Chrisogone","middleName":"J.","lastName":"German","suffix":""},{"id":444088213,"identity":"b4b04d02-d5ee-48ec-9d31-7c072c37810b","order_by":2,"name":"Patricia A. Materu","email":"","orcid":"","institution":"University of Dodoma","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"A.","lastName":"Materu","suffix":""},{"id":444088215,"identity":"8251e2d1-aea7-4222-aec0-0830ef43bd17","order_by":3,"name":"Pankras. Luoga","email":"","orcid":"","institution":"Muhimbili University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Pankras.","middleName":"","lastName":"Luoga","suffix":""},{"id":444088216,"identity":"97452882-2f19-463c-985c-c0a9199dcd5c","order_by":4,"name":"Mwajabu Machibya","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Mwajabu","middleName":"","lastName":"Machibya","suffix":""},{"id":444088217,"identity":"2c950a45-db6d-47ad-8b9a-1524f8af4b46","order_by":5,"name":"Radenta P. Bahegwa","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Radenta","middleName":"P.","lastName":"Bahegwa","suffix":""},{"id":444088218,"identity":"08913d33-e82d-410f-8fe3-c5cc7f23f668","order_by":6,"name":"Idda L. 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Kiwesa","email":"","orcid":"","institution":"President’s Office Regional Administration and Local Government","correspondingAuthor":false,"prefix":"","firstName":"Raymond","middleName":"R.","lastName":"Kiwesa","suffix":""},{"id":444088222,"identity":"562fa5b6-20ea-4ed1-a0db-7da0132bdcba","order_by":10,"name":"Erick S. Kinyenje","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Erick","middleName":"S.","lastName":"Kinyenje","suffix":""},{"id":444088223,"identity":"06f818ca-e165-4d53-b9c4-20d26dd16ada","order_by":11,"name":"Godfrey Kacholi","email":"","orcid":"","institution":"Mzumbe University","correspondingAuthor":false,"prefix":"","firstName":"Godfrey","middleName":"","lastName":"Kacholi","suffix":""},{"id":444088224,"identity":"96f5dd82-22d3-4e5d-986d-ba7358c7ac32","order_by":12,"name":"Ntuli A. Kapologwe","email":"","orcid":"","institution":"East, Central and Southern African Health Community","correspondingAuthor":false,"prefix":"","firstName":"Ntuli","middleName":"A.","lastName":"Kapologwe","suffix":""},{"id":444088225,"identity":"0b10e9bc-1c02-49cc-9be3-d457a9900138","order_by":13,"name":"Claud J. Kumalija","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Claud","middleName":"J.","lastName":"Kumalija","suffix":""},{"id":444088226,"identity":"344c4d04-3dbe-4697-8173-2524d171b3a5","order_by":14,"name":"Mackfallen G. Anasel","email":"","orcid":"","institution":"Mzumbe University","correspondingAuthor":false,"prefix":"","firstName":"Mackfallen","middleName":"G.","lastName":"Anasel","suffix":""},{"id":444088227,"identity":"6f023675-8f17-4692-8d82-9a56447cb0bc","order_by":15,"name":"Joseph C. Hokororo","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"C.","lastName":"Hokororo","suffix":""},{"id":444088228,"identity":"cad51a40-316c-487a-8835-014a578e04b9","order_by":16,"name":"Talhiya A. Yahya","email":"","orcid":"","institution":"Management Sciences for Health","correspondingAuthor":false,"prefix":"","firstName":"Talhiya","middleName":"A.","lastName":"Yahya","suffix":""},{"id":444088229,"identity":"c749b23e-5fb5-4f76-9482-af84adf27826","order_by":17,"name":"Eliudi S. Eliakimu","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Eliudi","middleName":"S.","lastName":"Eliakimu","suffix":""}],"badges":[],"createdAt":"2025-04-17 01:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6466987/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6466987/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80868164,"identity":"186c110e-51d6-4e34-9ce8-d386cf3e78f8","added_by":"auto","created_at":"2025-04-18 04:16:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249145,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Tanzania showing the distribution of visited regions\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSource: Sketch on data from National Bureau of Statistics 2021 (Mwaisengela, S.M, 2025)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/1ef23c191b0608e9c752cd21.png"},{"id":80868166,"identity":"c73c25c2-2b96-498e-b3c5-f585e001fdef","added_by":"auto","created_at":"2025-04-18 04:16:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76977,"visible":true,"origin":"","legend":"\u003cp\u003eRural and urban health facilities disparities in quality of healthcare\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/5df0dd53f372c4915d2c6145.png"},{"id":80868165,"identity":"18527cad-655c-4fb4-9caf-c7c21cbb55f2","added_by":"auto","created_at":"2025-04-18 04:16:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":96158,"visible":true,"origin":"","legend":"\u003cp\u003eRural and urban health facilities disparities in quality by facility ownership\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/0c8ce165a916ef8b3e058628.png"},{"id":80868167,"identity":"e944cbfc-28c8-4301-b376-502095a05cf3","added_by":"auto","created_at":"2025-04-18 04:16:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":114930,"visible":true,"origin":"","legend":"\u003cp\u003eRural and urban health facilities disparities in quality by facility level\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/3f0bb4663ac090f0c1ecab0c.png"},{"id":80868457,"identity":"9b93010d-d2f4-41eb-8b4c-3f7f50416fb9","added_by":"auto","created_at":"2025-04-18 04:24:48","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":343216,"visible":true,"origin":"","legend":"\u003cp\u003eRegional variation in\u003cstrong\u003e \u003c/strong\u003equality of healthcare among\u003cstrong\u003e \u003c/strong\u003eRural and urban health facilities\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/c491a4e1f98c343e74e0ea44.png"},{"id":81847355,"identity":"ae1debac-814a-4e90-85b0-a2ae72c70979","added_by":"auto","created_at":"2025-05-02 18:16:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1724491,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6466987/v1/767486a6-89e7-4145-a1dd-101b1442d33b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Who's Raising the Bar? A Comparative Analysis of Healthcare Quality in Rural and Urban Primary Care Settings in Tanzania","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorldwide, rural populations are recognized for being exposed to increased health challenges due to their living and working environment, socioeconomic status, and access to health services (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Michael Lipton\u0026rsquo;s 1977 Burban bias has cumulatively assumed urban areas are less vulnerable to development and interventions needed to target rural areas, if there remains a class conflict between the rural and urban populations resulting in the systematic under-development of rural areas and thus the persistence of poverty (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithout transformative policy changes to overhaul the centralized colonial healthcare system, the significant rural-urban divide in healthcare resources persists in Tanzania. The hospitals and dispensaries established during the colonial era were unevenly distributed across regions, creating inequities in Mental Health Care (MHC) (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Access to hospital-based MHC was restricted to women living in areas considered important to colonialists, with a greater emphasis on providing urban healthcare services rather than rural areas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis historical legacy reverberates through a rural-urban divide in healthcare, marked by the disproportionate distribution of mental health care in urban areas (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Health infrastructures in rural areas are likely to have inadequate drug supplies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), a lack of maternal health experts, and geographic isolation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The unequal distribution of healthcare facilities between rural and urban areas (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and the pyramidal healthcare system favor urban residents more than rural residents in Tanzania (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Tanzania, health services are delivered through a decentralized system that broadly falls into three functional levels namely Local Government Authority (LGA) which is the primary level, regional (secondary level), and referral hospital (tertiary level) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The LGA level provides Primary Healthcare (PHC) services through dispensaries and health centers. Dispensary serves as first point of contact of patient to health system while offering basic health services. Health center acts as the referral level for the dispensary and provides a slightly broader range of services, including inpatient care and level 1 hospitals as the top level serving as a referral center that includes council hospitals or council designated hospital (CDH). In councils where there is no government hospital, a service agreement is signed between government and a hospital run by a faith-based organization (referred as CDH) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePreviously, there was no reliable nationwide data source gathering information on the quality of healthcare in rural and urban settings. However, in 2014, the Government of Tanzania introduced the implementation of the \u0026ldquo;Big Results Now\u0026rdquo; initiative in the health sector, which resulted in the design of the Star Rating Assessment (SRA) as one of its interventions aiming at improving the performance of PHC facilities (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In the financial year 2015/2016, Tanzania Mainland conducted a countrywide assessment of all PHC facilities and assigned a star ranging from 0 to 5 stars based on the status of quality services. In 2017/2018, a countrywide re-assessment was done (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Star Rating Assessment Tool (SRT) covered twelve (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) service areas, namely Legality (Licensing and Certification), Health Facility Management, Use of Facility Data for Planning and Service Improvement, Staff Performance Assessment, Organization of Services, Handling Emergencies and Referral, Client Focus, Social Accountability, Facility Infrastructure, Infection Prevention and Control (IPC), Clinical Services, and Clinical Support Services.\u003c/p\u003e \u003cp\u003eMost of studies have focused rural and urban disparities in Health System Performance, patient satisfaction, services utilization, Health Information access and quality assessment on regional differences of patient satisfaction mostly in developed countries (\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However little research has been conducted on disparities in quality of healthcare between rural and Urban healthcare facilities in limited resources settings like Tanzania.\u003c/p\u003e \u003cp\u003eThis study is therefore dedicated to unveiling the prevailing variation across rural and urban settings in Tanzania as evidenced by the second-round Star Rating Assessment. This is the most recent assessment that was comprehensive enough to cover all twenty-six regions of the Tanzania mainland and was conducted in fiscal year 2017/2018.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study employed the analytical cross-sectional design to ascertain the rural and urban differences in compliance with Healthcare Quality Standards (HCQS) that signifies Quality of Healthcare among Primary Healthcare Facilities (PHCFs) using data collected during the re-assessment SRA conducted during the fiscal year 2017/2018.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eTanzania is a lower-middle-income country in East Africa, with a surface area estimated at 945,087 km\u003csup\u003e2\u003c/sup\u003e. According to the population and housing census (2022), Tanzania has a total population of 61,741,120, with 40,196,497 (65,1%) residing in urban areas whereas 21,544,623 (34.9) in rural (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Administratively, Tanzania mainland comprises 26 regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 139 Districts, 184 Councils, 570 Divisions, 3956 Wards, and 12319 villages (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Primary health facilities are categorized into three levels: district hospitals, health centers and dispensaries. As of 16th July 2023, there is a total of 6519 PHCs, of which 5582 (85.6%) are dispensaries, 767 (11.8%) are health centers, and 170 (2.6%) are district hospitals (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis paper aims to reveal the rural and urban differences in compliance with healthcare quality standards in Tanzania, located in the eastern part of Africa, which has 26 administrative regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The second assessment was conducted in the financial year 2017/2018, during which a total of 5933 PHC facilities, accounting for 81.4% of the visited health facilities, were extracted for analysis. 18.6% of the visited facilities were excluded due to missing values (\u0026gt;\u0026thinsp;5%) for most indicators necessary for compliance with healthcare quality standards (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \n\u003ch3\u003eData Source\u003c/h3\u003e\n\u003cp\u003eAs far as this study is concerned, data were sourced from Star Rating Assessment (SRA), which is an initiative belonging to the BRN workstream, namely \u003cem\u003ePerformance Management of Health Facilities.\u003c/em\u003e Data were collected from Star Rating Tools (SRT) for Dispensaries, Health Centers and District Hospitals.\u003c/p\u003e \u003cp\u003eRegardless of the level of service, the SRT is broken down into four domains: Domain A is for facility management and staff performance with service areas 1, 2, 3, and 4, namely legality, facility management, Health Management Information System, and staff performance and appraisal system respectively. Domain B is for service charters and social accountability with service areas 5, 6, 7, and 8, namely organization of services, emergency and referral system, client focus, and social accountability, respectively. Domain C is for safe and conducive facilities with service areas 9 and 10 namely facility infrastructure and Infection Prevention and Control (IPC) respectively and Domain D is for Quality of Care and Services with service areas 10 and 11 namely clinical services and clinical support services respectively.\u003c/p\u003e \u003cp\u003eWithin service areas, there are several indicators within which verification criteria denote quality standards that are to be met by a health facility (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). To date, three SRAs have been conducted where a baseline assessment was conducted in the fiscal year 2015/2016, the second assessment (reassessment) was conducted in the fiscal year 2017/2018, and the most recent assessment (third assessment) was conducted in the fiscal year 2021/2022 for only ten (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) regions. Therefore, the second assessment is the most recent assessment that was comprehensive enough to produce representative findings of which all twenty-six (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) regions were visited.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cp\u003eAs Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows, in this study, the dependent variable is compliance with HCQS that served as an outcome variable for all analyses conducted. The main independent variable was facility geographical location along with other variables (facility level and facility ownership) that are evidenced to be significant in as far as health systems performance and performance of quality indicators are concerned (\u003cspan additionalcitationids=\"CR29 CR30 CR31 CR32 CR33\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). These variables were used for comparative analysis of compliance with HCQS among rural and urban located PHC facilities.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariable Name\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable Type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVariable Definition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompliance with HCQS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealth facility compliance with HCQS is treated as categorical scores where aggregate scores encompassing six service areas namely organization of services, handling of emergencies and referrals, Infrastructure, Infection Prevention and Control, Clinical services and clinical support services. The \u003cem\u003eYes, Partial\u003c/em\u003e and \u003cem\u003eNo\u003c/em\u003e Responses to compliance with HCQS verification criteria for the aforementioned service areas were assigned 1,0.5 and 0 scores respectively. In this regard, sum of scores were considered as numerator while total number of compliances with HCQS verification criteria (Assuming that all criteria scored 1) as denominator and hence yielded final scores that ranged between 0 (0%) and 1 (100%). These scores were then dichotomized into \u003cem\u003e\u0026ldquo;Compliance\u0026rdquo;\u003c/em\u003e if scores were greater than or equal to 0.6 (60%) and \u0026ldquo;\u003cem\u003eNon-Compliance\u0026rdquo;\u003c/em\u003e if scores were less than 0.6 (60%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacility location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThis refers to geographical location of health facilities as defined by Tanzania National Human Settlement policy (2000) i.e. Urban or Rural located (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacility Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThis refers to facility level of services entailing District Hospital, Health Center or Dispensary the former being of higher level than the latter (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFacility ownership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThis refers to facility ownership entailing Public or Private owned health facilities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData management\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eData were extracted from the SRA database for each health facility. They were transposed and manipulated in Microsoft Excel to create a single dataset. The dataset was imported into Stata IC 18 for descriptive and inferential statistical analysis.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eData were geospatially visualized using Quantum Geographical Information Software (QGIS) 3.16 Hannover. A comparative analysis was conducted regionwide regarding facility characteristics, including facility level, location, and ownership. Proportion Z tests (one-sample and two-sample) and chi-square tests were used to compare proportions. In this study, analyses were performed to determine differences in compliance with HCQS among health facilities located in rural and urban areas concerning three performance categories: less than 40%, between 40% and less than 60%, and 60% and above, which were assigned as poor, good progress, and good coverage, respectively.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparative analysis was made for all 26 Tanzanian Mainland regions, by health facility level and facility ownership. The spatial regional variation documentation highlights the need to understand the broader subnational systems and context which may influence culture and effectiveness at the facility level and a health system as whole (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria\u003c/h2\u003e \u003cp\u003eSchafer (2016) suggests that, missing percentages of \u0026le;\u0026thinsp;5% are thought to be trivial otherwise, the results will be biased (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Therefore, the criteria for inclusion were all health facilities (Level 1 Hospitals, Health Centers, and dispensaries) visited during the second SRA (2017/2018), with less than 5% missing or invalid verification criteria necessary for estimating compliance with HCQS scores i.e. outcome variable of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria\u003c/h2\u003e \u003cp\u003eThe exclusion criteria were all health facilities with more than 5% missing verification criteria that were to be used to estimate the compliance with HCQS scores.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of health facilities involved in the analysis\u003c/h2\u003e \u003cp\u003eThis analysis involved a total of 5,933 PHC facilities, the majority of which were dispensaries (87.7%), rural located (78.3%), and public-owned (77.2%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of health facilities involved in the analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFacility Type\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Centres\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e652 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDispensaries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5201 (87.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacility Location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1285 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4648 (78.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFacility Ownership\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4578 (77.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1355 (22.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eRural vs urban health facilities and quality of healthcare\u003c/h2\u003e \u003cp\u003eA two-sample proportional Z test revealed that 46.9% (95% C.I 32.9% \u0026minus;\u0026thinsp;35.6%) of urban health facilities complied with HCQS. In contrast, 34.3% (95% C.I 32.9% \u0026minus;\u0026thinsp;35.6%) of rural health facilities met HCQS standards (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This difference is statistically significant, indicating that urban health facilities are significantly more likely to comply with quality indicators compared to their rural counterparts (z=-8.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRural vs urban health facilities and quality of care by facility ownership\u003c/h2\u003e \u003cp\u003eAs visualized in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, a two-sample proportional Z test revealed that among public health facilities, 35.3% (95% C.I 33.8% \u0026minus;\u0026thinsp;36.8%) of rural facilities complied with HCQS, while 51.8% (95% C.I 48.0% \u0026minus;\u0026thinsp;55.5%) of urban facilities complied with HCQS (z = -8.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, among private health facilities, 28.9% (95% C.I 25.7% \u0026minus;\u0026thinsp;32.1%) of rural facilities complied with HCQS, while 41.2% (95% C.I 37.2.0% \u0026minus;\u0026thinsp;45.2%) of urban facilities complied with HCQS (z = -4.75, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This indicates that, a more significant difference in compliance with HCQS between urban and rural located health facilities is observed when health facilities are public owned.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRural vs urban health facilities and quality of care by facility level\u003c/h2\u003e \u003cp\u003eAs Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows, among rural health facilities, an analysis showed a significant difference in compliance with HCQS among dispensaries, health centers and level 1 hospitals (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Chi}^{2}\\)\u003c/span\u003e\u003c/span\u003e=43.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). On the other hand, among urban-located health facilities, an analysis showed a non-significant difference in compliance with HCQS among dispensaries, health centers and level 1 hospitals (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Chi}^{2}\\)\u003c/span\u003e\u003c/span\u003e=0.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.651). This indicates that dispensaries, health centers and level 1 hospitals differ more significantly in terms of the quality of healthcare where health facilities are rurally located.\u003c/p\u003e \u003cp\u003eA two-sample proportional Z test revealed that among hospitals, 13.6% (95% C.I 4.8% \u0026minus;\u0026thinsp;22.3%) of rural health facilities complied with HCQS, while 38.1% (95% C.I 17.3% \u0026minus;\u0026thinsp;58.9%) of urban health facilities complied with HCQS (z = -2.41, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among health centers, 22.5% (95% C.I 18.7% \u0026minus;\u0026thinsp;26.4%) of rural health facilities complied with HCQS, while 45.6% (95% C.I 38.6% \u0026minus;\u0026thinsp;52.6%) of urban health facilities complied with HCQS (z = -5.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among dispensaries, 35.8% (95% C.I 34.4% \u0026minus;\u0026thinsp;37.3%) of rural health facilities complied with HCQS, while 47.3% (95% C.I 44.3% \u0026minus;\u0026thinsp;50.3%) of urban health facilities complied with HCQS (z = -6.87, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This indicates that, a more significant difference in compliance with HCQS between urban and rural located health facilities is observed when health facilities are of lower level (Dispensaries in this case).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRural vs urban health facilities and regional variations in compliance with HCQS\u003c/h2\u003e \u003cp\u003eAmong rural health facilities, the analysis showed a significant difference in health facilities that complied with HCQS in all twenty-six regions (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Chi}^{2}\\)\u003c/span\u003e\u003c/span\u003e=596.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). On the other hand, among urban-located health facilities, a significant difference in health facilities complied with HCQS among all regions was observed (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{Chi}^{2}\\)\u003c/span\u003e\u003c/span\u003e=147.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This indicates that regionwide, health facilities differ more significantly when they are rurally located (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe analysis shows that among rural-located health facilities, only the Geita region showed satisfactory coverage. Eight (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) regions showed good progress, while the remaining seventeen (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) regions had poor coverage (less than 40%).\u003c/p\u003e \u003cp\u003eOn the other hand, among urban-located health facilities, six (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) regions, namely Kagera, Shinyanga, Simiyu, Arusha, Kilimanjaro, and Dodoma, had satisfactory percentage coverage. Eight (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) regions showed good progress, while the remaining twelve (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) regions showed poor coverage.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study reveal substantial disparities in healthcare quality between rural and urban health facilities. Urban healthcare facilities generally have better-equipped hospitals, advanced medical technologies, and a higher density of skilled healthcare professionals compared to rural areas (\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). These advantages result in enhanced diagnostic capabilities, shorter waiting times, and improved health outcomes, reinforcing conclusions drawn from previous studies (\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Conversely, rural healthcare facilities often face significant shortages of medical equipment, essential medicines, and trained personnel, which hinder the delivery of quality healthcare services (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, findings indicate that healthcare quality varies significantly between public and private health facilities in both rural and urban areas. Private urban facilities typically demonstrate higher quality care due to better financing mechanisms, improved infrastructure, and a greater concentration of skilled personnel, which aligns with existing literature on the benefits of private sector healthcare (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) 40). Conversely, public rural facilities often encounter resource constraints that impede service quality, including frequent drug shortages and understaffing (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). These findings underscore the necessity for targeted resource allocation strategies to enhance the quality of care in public rural settings while leveraging efficiencies from the private sector to improve service delivery in underserved regions.\u003c/p\u003e \u003cp\u003eFindings show that variations in healthcare quality are also observed when comparing different levels of health facilities. Higher-level facilities (District hospitals in this case) provide superior quality care due to advanced medical technologies, specialized healthcare services, and better funding structures (47,48). Conversely, lower-level primary health facilities often struggle with inadequate medical supplies, fewer specialized healthcare providers, and infrastructural limitations (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). The disparity in quality across facility levels highlights the need for investment in lower-level health facilities, particularly in rural regions, to ensure that basic healthcare services meet quality standards and are accessible to all populations.\u003c/p\u003e "},{"header":"Conclusion and Recommendations","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003cp\u003eThis study reveals significant differences in healthcare quality between rural and urban settings, likely due to urban areas having better infrastructure, sustainable financing, and governance structures. Addressing these disparities requires comprehensive policy interventions, including improving infrastructure and the availability of health commodities, targeted subsidies for rural areas and enhanced insurance coverage to increase revenue collection for rural healthcare services, strengthening governance and facility autonomy in rural areas can also enhance efficiency and service delivery, as well as establishing incentive programs for the retention of healthcare professionals in rural settings. By implementing these measures, healthcare quality in rural areas can be improved leading to a more equitable and resilient healthcare system, embodying the \u003cem\u003e\"Health sector that ensures equitable, accessible, and quality health services for all Tanzanians.\"\u003c/em\u003e vision of Health Sector Strategic Plan V (2021\u0026ndash;2026) given that, over two-thirds of Tanzanians reside in rural areas rely on such health facilities for accessing healthcare services (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSMM analysed data and developed an initial draft, PAM and CJG cleaned and manipulated raw data into structured dataset, ESE, PL, LDM and PL had a critical role of reviewing the manuscript. All authors contributed to the critical review of interpretation of results, discussion of findings, conclusion and recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNo official funding was received by the authors for the study. Data manipulation and analysis was conducted as a part of usual responsibilities. Most of authors are from Health Quality Assurance Unit which is responsible in implementing SRA and hence obliged to disseminate evaluation results through publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eUpon request from the corresponding author,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe dataset used in the current study is available\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declared no conflict of interest. However, during the SRA of PHCs that yielded these data, Eliudi S. Eliakimu, Joseph C. Hokororo, Chrisogone J. German, and Talhiya A. Yahya worked with the Health Quality Assurance Division (now called the Health Quality Assurance Unit) and were responsible for implementing SRA and Quality Improvement Plans (QIPs) follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e This study did not involve human subjects; hence, for this type of study, formal consent is not required. However, prior permission was sought from the Ministry of Health before using data. Ethical clearance is not necessary for this type of a study because data were collected in the course of implementing government initiative (Star Rating Assessment) and hence this analysis aims at giving feedback after its successful implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimers:\u0026nbsp;\u003c/strong\u003eThe authors declare that the views expressed in this manuscript are their own and not an official position of any institution or funder for personal interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe authors would like to acknowledge the Ministry of Health for granting permission to use the SRA data. Furtherly, our sincere gratitude goes to key partners in the implementation of the SRA that include directorates and units of Ministry of Health embracing Health Quality Assurance Unit, Curative Services Division, Preventive Services Division and the Directorate of Health, Social Welfare and Nutrition Services of the President\u0026rsquo;s Office \u0026ndash; Regional Administration and Local Government (PO-RALG), development partners including the World Bank, Centres for Disease Control and Prevention, Danish International Development Agency, The World Health Organization, Association of Private Health Facilities in Tanzania, and Christian Social Services Commission. Nevertheless, Regional Secretariats, Local Government Authorities and Healthcare Workers in visited PHC Facilities in all 26 regions are highly acknowledged for their cooperation in the implementation of SRA.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBr\u0026icirc;ndușe LA, Eclemea I, Neculau AE, Păunescu BA, Bratu EC, Cucu MA. Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey. BMC Health Serv Res. 2024;24(1):1341.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipton M. Why Poor People Stay Poor: Urban Bias in World Development. London: Temple Smith; 1977.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShija AE, Msovela J, Mboera LEG. Maternal health in fifty years of Tanzania independence: Challenges and opportunities of reducing maternal mortality. Volume 13. Tanzania Journal of Health Research. National Institute for Medical Research; 2011. pp. 1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurshen M. The Impact of Colonialism on Health and Health Services in Tanzania. International Journal of Social Determinants of Health and Health Services [Internet]. 1977 [cited 2024 Sep 25]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://journals.sagepub.com/doi/\u003c/span\u003e\u003cspan address=\"https://journals.sagepub.com/doi/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2190/L9G4-KJVK-AW7A-Q9JD\u003c/span\u003e\u003cspan address=\"10.2190/L9G4-KJVK-AW7A-Q9JD\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurton A. Urbanization in East Africa, circa 900\u0026ndash;2010 CE. Volume 1. Oxford: Oxford University Press; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevira F, Todd G. Urban Health in Tanzania: Questioning the Urban Advantage. J Urb Health. 2017;94(3):437\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManzi F, Schellenberg JA, Hutton G, Wyss K, Mbuya C, Shirima K et al. Human resources for health care delivery in Tanzania: A multifaceted problem. Hum Resour Health. 2012;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSirili N, Frumence G, Kiwara A, Mwangu M, Anaeli A, Nyamhanga T et al. Retention of medical doctors at the district level: A qualitative study of experiences from Tanzania. BMC Health Serv Res. 2018;18(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsawe M, Moto A, Netshivhera T, Ralesego L, Nyathi C, Susuman AS. Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland. Int J Equity Health. 2015;14(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoex J, Fuller L, Malik A. Decentralized Local Health Services in Tanzania: Are Health Resources Reaching Primary Health Facilities, or Are They Getting Stuck at the District Level? 2015 Apr.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. Tanzania Maternal and Newborn Health Disparities. Dar Es Salaam; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrimary Healthcare System (PRIMASYS): Comprehensive case study from United Republic of Tanzania [Internet]. Geneva. 2017. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://apps.who.int/bookorders\u003c/span\u003e\u003cspan address=\"http://apps.who.int/bookorders\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapologwe NA, Meara JG, Kengia JT, Sonda Y, Gwajima D, Alidina S et al. Development and upgrading of public primary healthcare facilities with essential surgical services infrastructure: A strategy towards achieving universal health coverage in Tanzania. BMC Health Serv Res. 2020;20(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalukande M, von Schreeb J, Wladis A, Mbembati N, de Miranda H, Kruk ME, et al. Essential surgery at the district hospital: A retrospective descriptive analysis in three african countries. PLoS Med. 2010;7(3):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoHSW. Primary Health Services Development Programme (PHSDP.) 2007\u0026ndash;2017 [Internet]. Dar Es Salaam; 2007 Aug [cited 2022 Aug 6]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.frankshospitalworkshop.com/organisation/management_documents/Tanzania-Primary%20Health%20Services%20Development%20Programme%202007-2017%20-%20MoH%20Tanzania.pdf\u003c/span\u003e\u003cspan address=\"http://www.frankshospitalworkshop.com/organisation/management_documents/Tanzania-Primary%20Health%20Services%20Development%20Programme%202007-2017%20-%20MoH%20Tanzania.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eURT. National Key Result Area healthcare. 2015/16\u0026ndash;2017/18, Big Results Now roadmap [Internet]. Dar Es Salaam; 2015 [cited 2024 Sep 23]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pemandu.org/wp-content/uploads/2023/05/TZ-BRN-Healthcare-NKRA-Rev-11-web_English.pdf\u003c/span\u003e\u003cspan address=\"https://pemandu.org/wp-content/uploads/2023/05/TZ-BRN-Healthcare-NKRA-Rev-11-web_English.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGage AD, Yahya T, Kruk ME, Eliakimu E, Mohamed M, Shamba D, et al. Assessment of health facility quality improvements, united republic of Tanzania. Bull World Health Organ. 2020;98(12):849\u0026ndash;A858.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYahya T, Mohamed M. Raising a mirror to quality of care in Tanzania: the five-star assessment. The Lancet Global Health. Volume 6. Elsevier Ltd; 2018. pp. e1155\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman CJ, Mollel HA, Anasel MG, Yahya TA, Hokororo JC, Bahegwa RP, et al. Assessment of Implementation of the Star Rating System in Primary Health Facilities: Experience from Tanzania. J Service Sci Manage. 2023;16(03):249\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaya S, Bishwajit G, Ekholuenetale M, Shah V, Kadio B, Udenigwe O. Urban-rural difference in satisfaction with primary healthcare services in Ghana. BMC Health Serv Res. 2017;17(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpasojevic N, Vasilj I, Hrabac B, Celik D. Rural - Urban Differences in Health Care Quality Assessment. Materia Socio Med. 2015;27(6):409.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQin VM, McPake B, Raban MZ, Cowling TE, Alshamsan R, Chia KS et al. Rural and urban differences in health system performance among older Chinese adults: Cross-sectional analysis of a national sample. BMC Health Serv Res. 2020;20(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen X, Orom H, Hay JL, Waters EA, Schofield E, Li Y, et al. Differences in Rural and Urban Health Information Access and Use. J Rural Health. 2019;35(3):405\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYing M, Wang S, Bai C, Li Y. Rural-urban differences in health outcomes, healthcare use, and expenditures among older adults under universal health insurance in China. PLoS ONE. 2020;15(10 October).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNBS. Administrative units population distribution report [Internet]. Dodoma. 2022 [cited 2023 Jul 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nbs.go.tz/index.php/en/census-surveys/population-and-housing-census/852-2022-population-and-housing-census-administrative-units-population-distribution-and-age-sex-reports\u003c/span\u003e\u003cspan address=\"https://www.nbs.go.tz/index.php/en/census-surveys/population-and-housing-census/852-2022-population-and-housing-census-administrative-units-population-distribution-and-age-sex-reports\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoH. HFR web portal [Internet]. 2024 [cited 2023 Jul 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hfrs.moh.go.tz/web/index.php\u003c/span\u003e\u003cspan address=\"https://hfrs.moh.go.tz/web/index.php\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchafer J. Multiple imputation: a primer. Stat Methods Med Res. 2016;8(1):3\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinyenje ES, Yahya TA, Hokororo JC, Eliakimu ES, Mohamed MA, Degeh MM et al. Social accountability in primary health care facilities in Tanzania: Results from Star Rating Assessment. 2022; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0268405\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0268405\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman CC, Kinyenje ES, Yahya TA, Hokororo JC, Nungu S, Mohamed MA et al. The Use of Data for Planning and Services Improvement in Tanzanian Primary Healthcare Facilities: Experience from Star Rating Assessment. Journal of Service Science and Management [Internet]. 2023;16(02):144\u0026ndash;60. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162010\u003c/span\u003e\u003cspan address=\"https://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162010\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMwaisengela SM, Hokororo JC, German CJ, Kinyenje ES, Bahegwa RP, Yahya TA et al. Functionality of Primary Health Facilities Management Teams: Learning from 2017/2018\u0026rsquo;s Tanzania Star Rating Assessment. Journal of Service Science and Management [Internet]. 2023;16(02):94\u0026ndash;109. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162007\u003c/span\u003e\u003cspan address=\"https://www.scirp.org/journal/doi.aspx?doi=10.4236/jssm.2023.162007\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArsenault-Lapierre G, Bui TX, Le Berre M, Bergman H, Vedel I. Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review. BMC Health Serv Res. 2023;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVan Der Hoeven M, Kruger A, Greeff M. Differences in health care seeking behaviour between rural and urban communities in South Africa [Internet]. 2012. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.equityhealthj.com/content/11/1/31\u003c/span\u003e\u003cspan address=\"http://www.equityhealthj.com/content/11/1/31\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOladipo JA. Utilization of health care services in rural and urban areas: A determinant factor in planning and managing health care delivery systems. Afr Health Sci. 2014;14(2):322\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuigley DD, Chastain AM, Kang JA, Bronstein D, Dick AW, Stone PW et al. Systematic Review of Rural and Urban Differences in Care Provided by Home Health Agencies in the United States. Vol. 23, Journal of the American Medical Directors Association. Elsevier Inc.; 2022. p. 1653.e1-1653.e13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eURT. National Human Settlements Development Policy. Dar es Salaam; 2000 Jan.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacarayan EK, Ratcliffe HL, Otupiri E, Hirschhorn LR, Miller K, Lipsitz SR et al. Facility management associated with improved primary health care outcomes in Ghana. PLoS ONE. 2019;14(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDussault G, Franceschini MC. Not enough there, too many here: Understanding geographical imbalances in the distribution of the health workforce. Volume 4. Human Resources for Health; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShemdoe A, Mbaruku G, Dillip A, Bradley S, William JJ, Wason D et al. Explaining retention of healthcare workers in Tanzania: Moving on, coming to look, see and go, or stay? Hum Resour Health. 2016;14(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraujo E, Maeda A. How to recruit and retain health workers in rural and remote areas in developing countries [Internet]. Washington; 2013 [cited 2025 Apr 2]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldbank.org/en/topic/health/publication/how-to-recruit-retain-health-workers-in-rural-remote-areas-in-developing-countries\u003c/span\u003e\u003cspan address=\"https://www.worldbank.org/en/topic/health/publication/how-to-recruit-retain-health-workers-in-rural-remote-areas-in-developing-countries\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCulley EM, Mullachery PH, Ortigoza AF, Rodr\u0026iacute;guez DA, Diez Roux AV, Bilal U. Urban Scaling of Health Outcomes: a Scoping Review. Journal of Urban Health. Volume 99. Springer; 2022. pp. 409\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLanga N, Bhatta T, Erratum. The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization(PLoS ONE (2020) 15:11 (e0241746) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0241746\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0241746\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Vol. 18, PLoS ONE. Public Library of Science; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong J, Liu L, Miao H, Xia Y, Li D, Yang J et al. Urban health advantage and penalty in aging populations: a comparative study across major megacities in China. Lancet Reg Health West Pac. 2024;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBr\u0026icirc;ndușe LA, Eclemea I, Neculau AE, Păunescu BA, Bratu EC, Cucu MA. Rural versus urban healthcare through the lens of health behaviors and access to primary care: a post-hoc analysis of the Romanian health evaluation survey. BMC Health Serv Res. 2024;24(1):1341.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahman T, Gasbarro D, Alam K, Alam K. Rural\u0026ndash;urban disparities in household catastrophic health expenditure in Bangladesh: a multivariate decomposition analysis. Int J Equity Health. 2024;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeatty K, Heffernan M, Hale N, Meit M. Funding and service delivery in rural and urban local us health departments in 2010 and 2016. Am J Public Health. 2020;110(9):1293\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis TP, McConnell M, Aryal A, Irimu G, Mehata S, Mrisho M, et al. Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis. Lancet Glob Health. 2023;11(6):e862\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Zhong L, Yuan S, van de Klundert J. Why patients prefer high-level healthcare facilities: A qualitative study using focus groups in rural and urban China. BMJ Glob Health. 2018;3(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsei Afriyie D, Loo PS, Kuwawenaruwa A, Kassimu T, Fink G, Tediosi F et al. Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care. Soc Sci Med. 2024;347.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBintabara D, Mpondo BCT. Preparedness of lower-level health facilities and the associated factors for the outpatient primary care of hypertension: Evidence from Tanzanian national survey. PLoS ONE. 2018;13(2).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Urban, Rural, Primary Healthcare Facilities, Compliance, Quality Standards, Star Rating Assessment, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-6466987/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6466987/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eRural-urban disparities in quality of care and healthcare services utilization is a significant issue in both developed and developing countries. This leads to inequitable access to quality healthcare, poorer health outcomes and poor performance of a health system.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study is dedicated to unveiling the prevailing variation in quality of healthcare across rural and urban Primary Healthcare (PHC) settings in Tanzania.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis is a quantitative secondary data analysis using the Star Rating Assessment (SRA) data collected in the fiscal year 2017/2018. Compliance with HCQS was measured by considering service delivery areas of SRA Tool. With the aid of Stata 18, we used Chi Square and Proportion Z tests for comparative analyses in regard to facility level and facility ownership. Spatial variation by region were visualized with the aid of QGIS 3.8 Firenze.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study involved 5,933 PHCs, majority of which were rural located (78.3%), public owned (77.2%) and dispensaries (87.7%). On average, 46.9% (95% C.I 32.9% \u0026minus;\u0026thinsp;35.6%) of Urban health facilities, complied with HCQS compared to 34.3% (95% C.I 32.9% \u0026minus;\u0026thinsp;35.6%) of rural health facilities. This difference is statistically significant, indicating that urban health facilities are significantly more likely to comply with quality indicators compared to their rural counterparts (z=-8.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A disaggregated analysis by facility level and ownership showed higher variation in compliance with HCQS among rural compared to urban health facilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study demonstrates prevailing disparities in compliance with HCQS between Urban and Rural health facilities. To ensure equitable accessibility to quality healthcare services, this significant gap should be worked on including equitable allocation of HRH, improving infrastructure and the availability of health commodities in rural settings.\u003c/p\u003e","manuscriptTitle":"Who's Raising the Bar? A Comparative Analysis of Healthcare Quality in Rural and Urban Primary Care Settings in Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-18 04:16:43","doi":"10.21203/rs.3.rs-6466987/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3f8562b1-c4eb-401d-8056-abe0eab5ad9b","owner":[],"postedDate":"April 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-13T11:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-18 04:16:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6466987","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6466987","identity":"rs-6466987","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}