Dynamics of cost-sharing in urban healthcare: Evidence from a cross-case analysis in Tanzania

Cost-sharing remains a central healthcare financing strategy in many low- and middle-income countries, including Tanzania, where it supplements public health financing through out-of-pocket (OOP) payments and health insurance contributions. Despite its revenue-generating role, evidence on how different healthcare delivery models shape financial accessibility, affordability, and equity in urban settings remains limited. This study examined the dynamics of cost-sharing across referral-led, private-led, and city-led healthcare delivery models and assessed their implications for financial accessibility, affordability, and equity in urban Tanzania. A mixed-method, cross-sectional multiple-case study with cross-case analysis was conducted. Data were collected through household surveys, patient exit and inpatient interviews, and focus group discussions. Comparative analysis examined OOP expenditure, affordability, equity, quality of care, and regulatory compliance across the three healthcare models. Referral-led and private-led facilities incurred substantially higher treatment costs, increasing OOP payments and financial hardship among low-income households. City-led facilities were relatively more affordable because of lower user fees. However, weak enforcement of cost-sharing regulations and limited exemption mechanisms, particularly in private facilities, undermined equitable access to healthcare. Achieving equitable urban healthcare financing in Tanzania requires stronger regulation of cost-sharing practices, expanded financial protection and risk pooling, and effective pricing oversight, particularly within the private health sector.