equity implications of health sector user fees in tanzania

disproportionately, with the lowest income quintile capturing 50% from this policy change (Deininger et
al 2004:12 and 18 and Yates 2004: slide 22-24 and page 3).
Concerns and areas for attention haven been pointed out as well. It was found that the abolition of
user fees did not improve the situation for orphans, who were 3.8% more likely to be affected by
sickness after the reforms. This indicates that the impact of abolition of user fees has not been uniform
across the population and implies hat specific measures are needed for vulnerable groups. Health
workers (41%) have indicated that they felt they had a more negative attitude towards their work after
cost sharing ended. This was related to lack of funds to purchase additional drugs (29%) and to pay
support (non-skilled) staff (40%) which was not on the central payroll. Some supplies had reduced and
cleanliness and maintenance of health facilities had worsened substantially after the abolishment of
user fees. The Health Unit Management Committees (HUMC) largely have stopped meeting after cost
sharing ceased. They may have seen their job mainly as managing cost sharing funds. There is a
concern that the accountability to the community by health workers and health facilities will be
reduced. Although health workers seem to continue fulfilling professional responsibilities despite the
loss of income from the cost sharing revenue, they may in the long term shift to their private clinics to
compensate the loss of income and shorten the opening hours of government clinics (Burnham et al
2004: 189-194). It is emphasised that in order to maintain the gains of the policy change, it will be
critical to ensure the quality of services in public health facilities (with essential inputs and incentive
schemes for health workers) (Deininger et al, 2004:18-19).
It has been argued that the positive results are fragile in the sense that the difficulties of the public
sector with respect to drug supplies make the services vulnerable when emergency buffer funds
become exhausted. Yates has expressed concerns that the allocations for the health sector might be
affected by constraints (e.g. reduced levels of aid flows, views of development partners, sector ceilings
and sector competition) but emphasizes that for the achievement of the health Millennium
Development Goals (MDGs), the health budget should increase rapidly (absorption capacity is
sufficient and a bigger health budget will result in higher outputs) (Yates 2004: 32-27).
Abolition of userfees in Kenya
Very recently (1 st July 2004), Kenya introduced the abolishment of user fees in public dispensaries
and health centres. This is not as extensive as in Uganda where hospitals were included as well. With
this initiative Kenya hopes to improve access to medical care for approximately 9 million people who
live in absolute poverty (Press release, June 2004). Kenya also hopes to reverse the reverse the
health statistics especially for children under the age of five years and pregnant women. The
Government has set aside US $ 51.5 million to implement the free medical care programme in 2004/5.
The abolition of user fees will be combined with a mandatory membership in a National Social Health
Insurance Fund for all employed Kenyans. The Kenyan approach is considered as an important propoor
initiative which could set an example for Tanzania as well (at least very worthwhile to explore
further). Close monitoring of the impact of the Kenyan scheme will therefore provide more insight
about the relative costs and benefits with respect to services which are of benefit to the poorest
people.
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