equity implications of health sector user fees in tanzania

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� Under expenditure has been identified as a constraint. The budget performance in FY03 showed that the total expenditure was 89.9% (10.1% below the planned budgets). There is clearly room for improved budget performance and absorption capacity of available funding at different levels in the health system (PER 2004). � Funds do not always reach the intended beneficiaries. Although the allocation of health funds to the district councils has increased, widespread leakages of OC funds have been reported. The leakages include (1) a higher allocation of funds to administration and transport instead of medical equipment, utilities and training, (2) lack of transparency regarding the disbursements and allocation of funds to dispensaries and health centres. This has contributed to a reduced amount of funding and per capita expenditure actually used in the delivery of services (Poverty and Human Development Report 2002:82). Equity Implications of Health Sector User Fees in Tanzania 16
V COST SHARING STRATEGIES TANZANIA 5.1 User fees History and rationale for introducing user fees Already in 1988, the GOT planned to introduce a user fee for every patient seeking a consult in a public health unit. This initial idea was not pursued at that time since it was not clear what the revenue potential and cost sharing impact would be (Mushi, 1996:3). Cost-sharing was already common practice in the FBO health services but not in the public sector. During the 1980s and early 1990s, arguments against free public health services gained strength. Several studies argued that free public health services suffered from misuse and inefficiency. It was felt that the introduction of a small user fee would eliminate or at least minimize these problems (Msambichaka et al 2003:1). Early 1990s, the GOT reviewed its public health sector financing policy with the objective of introducing reforms that (1) would rationalize utilisation of public health facilities and (2) would mobilize additional resources for enhancing services in the Health sector. In 1992, a GOT comprehensive assessment concluded that the introduction of user fees would not deter people’s accessing to public health services. In view of these findings, the GOT proceeded with the development of a cost sharing implementation programme. The overall rationale for the introduction of user fees in Tanzania centred around two main ideas; (1) The need to mobilize additional resources for enhancing services in the Health sector and (2) to complement government budgetary allocations (see Technical Paper Part 3) Protection of vulnerable and groups In July 1993, user fees were introduced for Grade one and Grade two services 28 in public health facilities (Technical Paper Part 3). In January 1994, user fees were introduced for Grade three services in public hospitals (Msambichaka et al 2003:1). The revised user fee scheme of 1996 indicates that user fees for grade I, II and III medical services were differentiated and did not aim at full cost recovery but at cost sharing The protection of vulnerable and poor people was from the onset of the programme a major concern. For this reason, an exemption and waiver system was included in the user fee system. According to the cost sharing operationalisation manual for Tanzania, an exemption is a statutory entitlement to free public services, which is granted to individuals that automatically fall under the categories specified in the manual. Exemptions are to be extended to (1) children of five years and below, (2) MCH services including immunizations, and (3) patients with TB, Leprosy, Paralysis, Typhoid, Cancer, AIDS, and long-term mental disorders. Epidemics (e.g. Cholera, Meningitis, and Plague) are exempted as well. A waiver is granted to patients who do not automatically qualify for the statutory exemption but who are in need of an exemption as they are classified as “unable to pay”. People eligible for waivers include the elderly and other people “as might be decided by the hospital management” (Munga, 2004 and Mamdani 2003:6). Documented position of the GOT towards user fees in recent years Different documents reflect that the GOT has consistently been in favor of the user fee policy and its institutionalized protection mechanisms since the introduction of user fees in 1993. This is reflected in recent studies (PPC and Ministry of Finance 2001 and Rwechungura, 2003). However, the MOH also realized that the user fee policy did not protect the poorest groups sufficiently. For this reason the MOH commissioned a study in 2003 with the purpose to assess the impact of exemptions and waivers on the cost sharing revenue in public health facilities. The study concluded that cost sharing is still considered as a complementary source of revenue that should be strengthened in all public hospitals. The recommendations pointed to the need (1) to strengthen the management of the cost sharing programme, (2) to design incentives that will re-enforce collection of revenue and proper expenditure of the revenue, (3) for an effective policy on exemptions and waivers, (4) to re-design the statutory exemptions with the aim to target the poorest households and (5) to design strategies to alleviate the lost revenues due to exemptions (not indicated how) (Msambichaka et al 2003:28-29). 28 Grade one and two refer to first and second class services in Referral and Regional hospitals. This includes daily costs for medical services, food and admission charges. Grade three services are also charged at District level and in special clinics and include out-patient and in-patient services. The fees are charged for admission but exclude drugs, laboratory tests and other tests (Mushi, 1996:4 and User Fee Policy, 1996). Equity Implications of Health Sector User Fees in Tanzania 17
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 and 12: ACKNOWLEDGEMENT Many resource perso
Page 13 and 14: I INTRODUCTION 1.1 Background to th
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: Pro-poor observations Tanzania has
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
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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
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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
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� 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
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ANNEX 5 TANZANIA COUNTRY PROFILE 1.
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2. Tanzania Millennium Goals Countr
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ANNEX 6 RESOURCE PERSONS Name of Re
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ANNEX 7 ITINERARIES 1. Itinerary Pa
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03-04-2004 � Continued desk study
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ANNEX 8 MAP OF TANZANIA Equity Impl
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