equity implications of health sector user fees in tanzania

packages and formal coordination between CBHI schemes and government financing schemes
appears to be limited (Bennett, 2004).
Differences in design of CBHI schemes
CBHI schemes differ markedly in terms of their ownership structures, benefit package composition and
membership. Some countries have multiple risk-pooling schemes, meaning that a CBHI scheme runs
parallel with other social security schemes and different CHFs in other districts. However, there is very
little empirical evidence about the consequences of the multiple risk pools in developing country
contexts. There is evidence that members and health workers “shift” between different schemes to
obtain the best coverage and benefits. There is sofar limited understanding on the impact of multiple
risk pools on financial sustainability and how the mix of payment systems used by such schemes
affects outcomes and whether the outcomes will be acceptable (Bennet, 2004).
Beneficial for the poor?
The design and coverage of the CBHI scheme (less or more pro-poor) will determine the preferred
option by communities. A pro-poor approach is if CBHI schemes will cover the payment of copayments.
Some studies have indicated that it is desirable for poorer people to joint CBHI schemes
since it seems likely that this will promote access to basic services, but according to Bennet it is not
clear that this is the best strategy to promote the progressive distribution of subsidies. A high
membership amongst very poor households in CBHI schemes might be counter to equity goals if the
Government operates a parallel system of programmes to provide free health care services for elderly,
school children and the poorest households. A main concern is what will happen to non-members
since it is unlikely that there will other safety nets for those who do not (or cannot) join the CBHI
scheme. It is possible that non-members might actually be made worse off by a CBHI scheme than
before (e.g. by increase in prices for non-members, preferential access for members, increased
Government funding to CBHI schemes). There is therefore a great need for further research to
enhance the understanding of the linkage between the CBHI schemes and health system wide goals
(Bennett, 2004).
2.5 Documentation on abolition of user fees
Abolition of user fees for Primary Education in Tanzania
Most governments and donors have favoured the concept of cost-sharing in the health and education
sectors as an appropriate strategy. It was believed that it was the only financially-viable alternative and
that it would enhance parent ownership of their children’s education. In recent years, this concept has
become subject of serious scrutiny and re-thinking. As a result, some countries have abolished user
fees for education (Tanzania) and health (Uganda and Kenya).
A clear pro-poor policy has been adopted in Tanzania with the elimination of the Enrolment Fee for
Primary Education in 2001. The deterioration of educational outcomes in the 1990s 12 was related to a
combination of rising costs and a declining quality and returns of education. Although people already
had to contribute to the costs of education, a primary school enrolment fee of Tshs. 2,000/= was
formally introduced in 1995. The fees were particular regressive for poor people and as a result
children were kept out of school. Since the university education remained free of charge, the
government expenditure was highly regressive since the highest income quintile received more than
twice the share of the overall public expenditure on education received by the lowest quintile (Terme,
2002:1-6). Social discontent, the PRSP process, activism of civil society organisations (CSOs) in
Tanzania and the North, and the turn-around of the Tanzanian government and the donor community
were crucial to gain support for the elimination of the enrolment fee.
In formal policy documents (2000), the Government still considered cost-sharing as an essential
component of primary education expansion but when it became clear that the donor community was
willing to support the elimination of user fees for primary education, the government of Tanzania
announced in 2000 in its PRSP the abolition of primary school fees in order to ensure that children,
particularly from poor families, would have access to primary education. The Primary Education
Development Programme (PEDP) was prepared and was supported with a US$ 150 million World
Bank project loan. The financing gap was estimated at US$ 450 for a period of three years and was
12 A decline in gross enrollment in primary education from 100% in 1980 to 82% in 1993 and increased illiteracy
between 1986 and 1992 increased from 10 to 16%.
Equity Implications of Health Sector User Fees in Tanzania 6