equity implications of health sector user fees in tanzania

In a 1996 review of user fee systems in Africa, the following conflicting impacts were noted:
� Fees by themselves tend to dissuade the poor from using health services more than the rich
and are associated both with delays in accessing care and with increased use of selfmedication
and informal sources of care
� If fees are associated with quality improvements, this offsets their negative impact on
utilization; the introduction of fees plus quality improvements may even generate utilization
increases among the poorest
� Fees do not appear to generate adequate revenue or to be associated with the resource reallocations
necessary to enable substantial and sustained improvements in health care for the
poor
� The implementation of both formal and informal exemptions or sliding scales that could protect
the poor from the full burden of fees is usually ineffective
Numerous studies point to regressive outcomes of fees including in Zimbabwe where women limited
their ante-natal care and gave birth at home in higher numbers; in a regional hospital in Nigeria where
maternal deaths rose by 56 percent along with a 46 percent decline in deliveries after introduction of
fees; in Tanzania where a decline of 53 percent among outpatients visits in public hospitals was noted
after fees were introduced; in Kenya where the introduction of fees in government outpatient facilities
led to a reduction in utilization of STD services; and in Swaziland where people most affected by the
introduction of fees were patients who are either low income, need to make multiple visits, or who
decide their illness is not serious enough to justify the costs of care.
As a result of this and other evidence there is an increasing concern about the impact of user fees on
the poor and a declining popularity of user fees as a health care financing mechanism in the
international policy literature. For the most part, the supposed benefits have not been supported by
evidence and the international policy climate has shifted the balance of emphasis from efficiency to
equity.
Tanzania has already introduced user fees at the hospital level and is preparing to further introduce
fees at the dispensary and health centre levels (in some districts primary level facilities are already
charging official fees). Particularly given the need to increase revenue within the sector and concerns
about “donor fatigue” and long-term sustainability, many people argue that fees are critical to
maintaining both basic and tertiary health services in the country.
At the same time, others have raised the concern that user fees are limiting the capacity of poor
people to get care. The recently concluded Policy and Service Satisfaction Survey, Tanzania
Participatory Poverty Assessment and “gray literature” point to the grave dilemma that poor people
face in paying for health care: forced to pay for services, they are thrust into even greater poverty.
The imperative to raise revenue for services and to strive for sustainability is real and valid goals. The
dilemma then becomes how to achieve these goals without excluding the poorest Tanzanians from
health care, particularly at the primary levels. A strong exemption system may be part of the answer,
although various studies point to the misuse of exemptions in clinic settings; nearly non-existent
records and monitoring systems for exemptions; leakages to the non-poor; and, discretionary waiving
of fees or application of fees.
Objective and key issues
This analysis seeks to examine how much is gained by user fees in the health sector as compared to
the impact of fees on poor people’s access to health services. Special attention will be focused at the
primary level of care: dispensaries and health centres.
In particular, this study will examine:
1. The impact of user fees in the health sector overall in relation to:
� New resources generated and used at the facility level
� Local ownership and accountability, and provider responsiveness resulting from fees
� Whether and how revenue generated by fees is used to improve services
� Transaction costs and administration requirements of implementing the system, to the
extent this information is available in the literature
Equity Implications of Health Sector User Fees in Tanzania II