"If You Have No Money, You Might Die": A Qualitative Study of Sociocultural and Health System Barriers to Care for Decedent Febrile Inpatients in Northern Tanzania.

Infectious diseases are a leading cause of mortality in low- and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.