equity implications of health sector user fees in tanzania

diseases, (3) reducing malnutrition and (4) achieving a drastic reduction of income poverty (Human
Development Report 2002:34 and Poverty and Human Development Report 2002:105). Tanzania has
also committed itself to achieving the Millennium Development Goals (MDGs). It is foreseen, however,
that the worrying health trends will also negatively affect the achievement of the health related MDGs
number 4, 5 and 6 (see annex 5).
3.3 The position of health in the PRSP
Health addressed in the PRSP
The study team analysed key health related issues in the Tanzanian PRSP by making use of a selfdesigned
assessment tool (Annex 4; based on Laterveer et al, 2003) and an analysis carried out by
the Word Health Organisation (WHO 2003). Table 3.4 presents the outcomes of these analyses.
Table 3.4: Health as addressed by the PRSP of Tanzania
1. Health is an important component of the Tanzanian PRSP. The paper identifies ‘disease’ as one of the three
national ‘development problems’. It recognizes the particular role of health in the context of poverty reduction,
by identifying it as one of the priority sectors for improving human capabilities, survival and social well-being.
2. The health sector strategy proposed by the PRSP is rather disease-oriented, with less attention for examining
or addressing underlying health system weaknesses. The focus is mainly on reducing infant and child
mortality rates and the burden of communicable diseases, especially HIV/AIDS and malaria. Improving health
services provision, especially primary health care, and boosting health awareness, particularly on nutrition
and HIV/AIDS, are also mentioned. This indicates an implicit pro-poor approach. However, the difficulties of
achieving the set targets in the poorest areas and groups are not discussed.
3. The PRSP and the progress reports indicate a lack of poverty-related health data, despite the commendable
efforts of the government to obtain such information. Studies to analyze and describe the distribution of the
burden of disease across the population, the prevailing health system constraints and the impact of health
services, particularly in relation to the poor, are not mentioned. The focus is mainly on the general population.
4. The PRSP does include a number of specific concerns expressed by the poor: (1) limited access to quality
health services, causing (deeper) poverty, (2) the unsatisfactory level of service provision, especially in the
rural (poorest) areas, and (3) their limited involvement in designing health plans and programs. Poor people
also expressed their concern about the low standard of health education. The PRSP acknowledges only
some of the raised concerns, notably the poor condition of health facilities and the low quality of services.
5. Reducing vulnerability is part of both the PRSP and progress reports. According to the PRSP, ‘many
communities are forced to deal with a growing number of AIDS victims and orphans, the handicapped, the
very old and refugees, and there is a growing need for safety-nets’. The PRSP and progress reports do not
explicitly address the position of women (gender), the disabled, and/or HIV/AIDS clients in relation to health.
Addressing extreme vulnerability is said to be a part of future poverty reduction policies.
Analysis based on Tanzanian PRSP and PRSP related documents
Financial barriers to health for the poor addressed in the PRSP?
The study team also assessed what is stated on cost-sharing, user fees and the impact of user fees in
the PRSP and the progress reports. The key findings are presented in Table 3.5.
Table 3.5: To what extent are financial barriers to health addressed in the PRSP?
1. The PRSP states the commitment to increase health spending.
2. The PRSP does not explicitly mention cost-sharing or user fees in relation to health, while doing so
extensively for education (i.e. it announces the abolition of user fees) The rationale for different user fees
strategies for the education and health sectors is not explained.
3. The progress (01/02) report does explicitly address cost-sharing. It reports the introduction of the Drug
Revolving Fund (DRF) in all district hospitals; the introduction of Community Health Funds (CHF) in nearly 40
districts; and the operational National Health Insurance Fund (NHIF) enrolling all civil servants.
4. The progress report concludes that ‘the introduction of health care financing options including CHF and user
fees have improved availability, access, provision and use of services by beneficiaries as drugs are now
available in health facilities all the time.’ The report does not explain the policy rationale for the continuation
and/or further introduction of user fees in the health sector. Neither does it distinct between user fees for
public and private services, nor explains at what service levels user fees are charged.
5. The PRSP and the progress reports do not discuss financial and non-financial barriers for the poor to access
health services; or examine which specific groups do not have access. They do not propose measures to
protect the poor against possible adverse impacts of user fees, such as exclusion, or reduced (financial or
geographical) access or use (i.e. equity, which is not mentioned in the documents). They do not mention
waiver and exemption schemes or pay attention to implementing or strengthening existing schemes. They do
not report on the impact of user fees in the health sector (other than for drugs), in general or in relation to the
poor. The same can be said for the CHF.
Analysis based on Tanzanian PRSP and PRSP related documents
Equity Implications of Health Sector User Fees in Tanzania 11