To our knowledge, this is the first study analysing the responsiveness of health care services in Tanzania by insurance status. In this section, we first discuss the performance of the different domains and then the difference in responsiveness perceived by the insured and the uninsured elderly.
Responsiveness in outpatient and inpatient care
Based on our findings, both the insured and uninsured elderly reported good responsiveness (very good/good/moderate ≥50%) in all domains of outpatient and inpatient care. High scores in all domains were also found in the Tanzanian study that explored responsiveness in primary health care among the general population . In our study, the perceived health care responsiveness was, however, lower among the insured compared to the uninsured elderly in all domains of both types of care. Our results are in line with the findings of similar studies from sub-Saharan Africa. In a study conducted in South Africa among insured and uninsured older adults (50 years and above), a good health system responsiveness was observed in all domains of outpatient and inpatient care . Similar experiences have been reported by insured and uninsured patients in Nigeria, who indicated a high responsiveness in outpatient care .
Three domains – access (ease of seeing a health provider), confidentiality (privacy) and autonomy (involvement in decision-making) – performed better among both the insured and uninsured elderly in outpatient and inpatient care services. This finding differs from the results of the previous South African study , which reported patient dissatisfaction with the access and autonomy domains of the health care system. The observed better responsiveness concerning access shown in our study may be a result of the government’s ongoing efforts to improve service delivery, particularly at the primary health care level, which is widely available in rural areas. According to Röttger et al. , users of health care services expect a high level of privacy and assurance that whatever personal information they discuss with health care providers is safeguarded. In our study, the confidentiality domain performed satisfactorily, similar to the South African study  that reported high responsiveness (74.2%) in that domain. However, in our study setting, many health facilities were small, had limited space for patient–doctor meetings and used the available space for multiple activities. It could be that elderly patients were comfortable with the level of confidentiality because it had recently improved, and/or they did not have other experience to compare. Nevertheless, there is a need to readjust the facility’s space and remind health care providers of the ethics of information privacy. Autonomy describes the rights of a patient to medical information and to make informed choices . Involving the elderly in making decisions about their health may enhance patient–doctor relationships, which are important in the care process . Although information asymmetry is common in health care settings, the findings from our study appear to highlight an existing good relationship between health care providers and patients in the sense that it gives the patient a sense of control and responsibility and hence, allows them to be involved in the care activity .
Our results revealed a concern by the elderly regarding three responsiveness domains: prompt attention (waiting time), quality of basic amenities (cleanliness) and communication (clear explanations). These findings are similar to previous studies on health care responsiveness among older adults in South Africa , China  and Nigeria . Nevertheless, our scores regarding prompt attention were extremely low (18.15% in outpatient and 21.85% in inpatient care) compared to those of South Africa (58.2% for outpatient and 68.6% for inpatient) and Nigeria (68% for outpatient care). In line with other research, dissatisfaction of the elderly may be associated with overcrowding, understaffing, limited geriatric skills, delays in reception, unavailability of recommended medicine, attitude of providers towards the elderly and processing insurance claims [11, 37, 38]. Similar to prompt attention, neither insured nor uninsured patients were satisfied with the cleanliness of the facilities. These findings are different from other studies [26, 37] in which this domain was scored highly and deemed important. In our study, cleanliness was perceived as poor (21.35%) for inpatient care compared to the South African study, which was 71.3% . There is definitely a need for health care managers to improve the cleanliness of their facilities in order to offer a quality service. In line with the WHO , communication is also very important in improving the delivery and utilisation of health care. However, the dissatisfaction observed with communication in this study may imply that providers do not take enough time to listen to and understand the problems of elderly patients. This is a not a good practice, as it disempowers the service users, makes them feel uncomfortable with the provider and may lead to decreased trust in the health care delivery system.
Factors associated with responsiveness
The elderly with HI reported worse responsiveness compared to the uninsured, in the adjusted quantile regression models. This finding can appear to be contradictory at first sight. Although research from Ghana has shown similar results , in which insured patients tended to perceive worse quality of health care, a study from Burkina Faso  showed no difference in the quality of health care among insured and uninsured patients. Two main reasons could be argued for the difference in our study: difference in procedures when visiting a health facility and unfulfilled expectations. In the Tanzanian health care setting, an insured elderly person has to go through a long process before being seen by a doctor. They start by submitting the insurance card at the reception and then wait while undergoing verification through the computer system, which may take a long time due to overcrowding. However, the uninsured pay cash and get the services immediately, which is a quicker process with commonly shorter queues than that of the insured patients. Furthermore, the fact that patients are given appointments for a particular day but not time, and may not be seen immediately due to the ‘first come-first-served’ modality, added to the overcrowding of health facilities particularly in the insured section, can contribute to this finding . A similar experience from Ghana showed that dissatisfaction of the insured was associated with long waiting times, inadequate information regarding services, poor staff attitudes, non-observance of the queuing process and perceived low quality of drugs . Related to the second explanation, insured patients may expect to be attended by professionals who show concern for and understanding of their health problems, to experience shorter waiting times and to receive better quality services than the uninsured. If this does not happen, responsiveness can be perceived as being worse.
Among the independent variables, older age, female and being married showed a negative statistically significant association to responsiveness in outpatient care. The result regarding age is, however, opposite to other studies [9, 15] that have reported more responsiveness by older people. One possible explanation might be that health care services are used more often with age, making elderly more negative towards them. Literature offers different findings regarding gender and responsiveness. In the South African study, female inpatients indicated higher health care responsiveness , whereas in studies from Ethiopia  and Ghana , gender differences did not influence the responsiveness perception among older patients. This difference might require further exploration. Higher educational attainment tended to be positively associated with perceived responsiveness in outpatient and inpatient care. This finding is similar to other studies [42,43,44] which showed increased responsiveness with higher education, but it differs from the findings of a study in Ethiopia . A probable explanation might be that elderly people with higher education have a better knowledge of what services they need, as well as greater ability to interact with the providers and navigate within the system .
The survey used to explore the responsiveness of health care services was based on the responsiveness questions included in the WHO multi-country responsiveness survey study , which allowed for consistency and comparison with other studies. The response rate was high (above 80%), probably due to the recruitment of research assistants who were fluent in the local language and the culture of the study respondents. The fact that our sample size was relatively high, with both males and females represented, increases the internal validity of our findings. However, generalisation of the results to other parts of the country should be undertaken cautiously. Several measures were taken to minimise the possibilities of bias and misinterpretation by both the interviewers and the respondents. In order to reduce interviewer misinterpretation and thus respondent bias, we conducted a pilot test of the instrument, with thorough training for the research assistants. The responsiveness questions related to health care utilisation might have created recall bias. This was partly dealt with by requesting to see HI cards and hospital registration numbers for a randomly selected number of respondents during interviews. Selection bias was partly taken into consideration because of the randomisation process of the participants’ selection. Finally, we could not distinguish to which kind of HI participants belonged, which could have influenced the perception of the responsiveness domains.