equity implications of health sector user fees in tanzania

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Equity Implications of Health Sector User Fees in Tanzania x
I INTRODUCTION 1.1 Background to the study The Research and Analysis Working Group (R&AWG) of Research for Poverty Alleviation (REPOA) commissioned the public health consultancy group ETC Crystal to carry out an in-depth analysis of the Equity Implications of the Health Sector User Fees in Tanzania. The study was carried out in the period 3 rd March to the 5 th June 2004 by Ms. Leontien Laterveer, Mr. Michael Munga and Ms. Patricia Schwerzel. The Terms of Reference (TOR) was the guiding document for the study (see Annex I). 1.2 Purpose and objectives of the analysis With the findings of the analysis, REPOA aims at making a meaningful contribution to the Poverty Reduction Strategy (PRS) Review Process taking place this year in Tanzania. The main purpose of the analysis was to examine the equity implications of the user fee system in Tanzania with particular reference to proposed and actual charges at Primary Health Care (PHC) facilities. 1 The analysis aimed to address one of the guiding PRS questions in relation to health: “The Government should consider suspending cost sharing for basic health services at least until the time when an effective system of exemptions for the poor is in place. In preparing for this, a cost-benefit assessment should be undertaken to determine how much is gained by fees as compared to how much is lost by excluding the poor.” (Statement made during a Poverty Reduction workshop, 2003) The main objective of the analysis was to examine how much is gained by the user fees in the health sector as compared to the impact of fees on the access of poor people to health care services, especially at the primary level of care. The analysis examined the following critical issues: 1. The impact of user fees in the overall health sector and more specifically in relation to (1) their contribution to the overall resource envelop, (2) resources generated and used at facility level, (3) contribution of generated revenue to improved services, (4) transaction costs and administration requirements, (5) payment of “unofficial fees” by the poor, (6) local ownership, accountability and provider responsiveness, (7) access to services for the poor, and (8) effectiveness of exemption and waiver mechanisms. 2. The potential impacts of further extension of user fees to the dispensary and health centre level in relation to the issues mentioned under 1. 3. Options that exist for revising the current user fee system to achieve greater equity and effectiveness. 1.3 Equity definition, research questions and methodology Working definition of Equity In the literature a wide range of definitions of equity 2 can be found. The study team opted for a working definition which is much in line with the priorities mentioned in the TOR and by the members of R&AWG: Equity means that everyone should, in practice, and not just in theory, be able to access and use appropriate health services. Health services should not only be for the dominant population group. This implies equitable access and use, given that some people will need more health care than others. It also means that we should seek to minimize inequalities in health outcomes. The main elements of a just health care system can be listed as universal access, access to responsive care and fairness in financing (Healy and Mckee, 2004). 1 PHC facilities include Health Centers and Dispensaries 2 A distinction must be made between equity and equality. Whereas equity deals with fairness, equality is concerned with equal shares (Carr-Hill 1994:1190; Donaldson & Gerard 1993:73; Wagstaff, Van Doorslaer & Paci 1991:145; in Laterveer, 2001). Equity Implications of Health Sector User Fees in Tanzania 1
Page 1 and 2: C R Y S T A L EQUITY IMPLICATIONS O
Page 3 and 4: TABLE OF CONTENT ABBREVIATIONS ....
Page 5 and 6: ABBREVIATIONS AIDS Acquired Immune
Page 7 and 8: EXECUTIVE SUMMARY 1. Background Ear
Page 9 and 10: Tanzania has opted for a system of
Page 11: ACKNOWLEDGEMENT Many resource perso
Page 15 and 16: II LITERATURE REVIEW 2.1 Introducti
Page 17 and 18: have been highlighted in Technical
Page 19 and 20: met with donor support. After the a
Page 21 and 22: III POVERTY AND HEALTH IN TANZANIA
Page 23 and 24: diseases, (3) reducing malnutrition
Page 25 and 26: VI HEALTH SECTOR STRATEGIES TANZANI
Page 27 and 28: Pro-poor observations Tanzania has
Page 29 and 30: V COST SHARING STRATEGIES TANZANIA
Page 31 and 32: eported income proportion for the h
Page 33 and 34: VI IMPACT OF USER FEES IN TANZANIA
Page 35 and 36: An indication of actual charges and
Page 37 and 38: Table 6.3: Critical observations re
Page 39 and 40: All in all, there is limited eviden
Page 41 and 42: User fee policy Stakeholders mostly
Page 43 and 44: persons suggested to design a polic
Page 45 and 46: eneficiaries such as identity numbe
Page 47 and 48: VII CONCLUSIONS Poverty and health
Page 49 and 50: Importance of the public PHC facili
Page 51 and 52: � In the absence of effective per
Page 53 and 54: LIST OF CONSULTED DOCUMENTS 50 Year
Page 55 and 56: Gilson, L. 1997. ‘The Lessons of
Page 57 and 58: Ministry of Health. 2003. Assessmen
Page 59 and 60: Schwerzel, P. 2001. Evaluation Repo
Page 61 and 62: World Bank. 2000. Poverty Reduction
Page 63:
TECHNICAL PAPER
Page 66 and 67:
2. Groups with most regressive outc
Page 68 and 69:
Although the primary purpose is to
Page 70 and 71:
Technical Paper 6
Page 72 and 73:
Health Sector Reforms: Strategic Pl
Page 74 and 75:
Technical Paper 10
Page 76 and 77:
Elements of the Community Health Fu
Page 78 and 79:
stems from the rapid increase in de
Page 80 and 81:
Technical Paper 16
Page 82 and 83:
Type of service Clarifications Refe
Page 84 and 85:
Charges in the public and private h
Page 86 and 87:
� Implementation of fees at the l
Page 88 and 89:
- Enhance the accessibility of serv
Page 90 and 91:
Technical Paper 26
Page 92 and 93:
Critical factors that hamper access
Page 94 and 95:
An exploratory study 11 in Kagera R
Page 96 and 97:
Table TP 15 Views of 4 orphans towa
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this way the health centre prevents
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dispensaries. That is where most of
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ANNEX 1 TERMS OF REFERENCE Equity I
Page 105 and 106:
� Access to services for the poor
Page 107 and 108:
ANNEX 2 DATA MATRIX FOR CATEGORISAT
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(These are the key questions in the
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ANNEX 3 GUIDELINES FOR DATA COLLECT
Page 113 and 114:
� Can you mention negative experi
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� Which groups are exempted from
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ANNEX 4 TOOL FOR ANALYSIS OF POVERT
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c.3 User fees 19. Does the strategy
Page 121 and 122:
ANNEX 5 TANZANIA COUNTRY PROFILE 1.
Page 123 and 124:
2. Tanzania Millennium Goals Countr
Page 125 and 126:
ANNEX 6 RESOURCE PERSONS Name of Re
Page 127 and 128:
ANNEX 7 ITINERARIES 1. Itinerary Pa
Page 129 and 130:
03-04-2004 � Continued desk study
Page 131:
ANNEX 8 MAP OF TANZANIA Equity Impl
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