equity implications of health sector user fees in tanzania

VI IMPACT OF USER FEES IN TANZANIA
6.1 User Fee charges
Actual charges and proposed charges at PHC level
It was difficult to obtain differentiated quantitative data on the actual user fees currently charged in the
public and private sector (non-profit and for-profit) at health centre and dispensary level. Costing
studies (HERA, 1999) reflect the actual costs of health services at health centre and dispensary level
and relate this to the required income for health facilities at PHC level, but do not indicate the actual
fees charged. According to MOH representatives in Kagera Region, the PHC facilities are suggested
to follow the formal user fee charges given for District hospitals.
The Health and Education Financial Tracking Study (1999) found that non-governmental health
facilities in most cases charge higher user fees than government facilities. This was also confirmed in
Kagera Region (see Technical Paper Part 5). Information that is available on user charges in the
public facilities never includes the additional costs that people have to incur for transport, purchase of
drugs or items that are supposed to be free of charge, unofficial fees, etc. Table 6.1 indicates that
people often have to incur substantial extra costs on top of the formal user fee charges.
Table 6.1: User fee charged in different public health facilities, 2003
Source of Care Formal User fee charged Excluding costs for;
GOT-HC 1 � Registration costs Tshs. � Medicine which are not available in the HC
100/=
�
�
Medicine available in the HC
Transport costs from home and 2 nd visit to collect lab
results
� Food in case of admission
� Long waiting time if you do not have money
� Referral costs to Hospital (Tshs 8,000/=)
GOT-HC 2 � ANC card Tshs. 500/= � Syringe, Tshs 200/=
� Gloves, Tshs 2,000/=
� ‘Thank you’ for staff, Tshs. 5,000/=
� Transport costs
GOT-
� Registration Fee Tshs. � Medicine which are not available
dispensary
50/=
� Transport cost from home
Extracted from SDC 2003:31-33 and TzPPA 2003:98
Huge variations in charges to be paid have been noted. The MOH/DFID PER Update 2002 mentioned
that for hospitals where user fee income was reported, the overall average annual user fee per person
was Tshs. 130/=. 31 There was, however, a wide variation, from an average of Tshs. 12/= per person in
Mafinga District Hospital to Tshs. 994/= per person in Amana District Hospital. This indicates that it is
difficult to establish precisely what people actually pay for the costs of health services both for formal
charges, informal charges and additional costs if the required services cannot be obtained at one
health facility during one visit.
Differentiated use of public and private health facilities by the poor and rich people
Although there is huge variation in the reported individual user fee charges, it was clear from different
studies that the lower charges in the public health facilities are preferred by both the poorer and richer
segment of the population. The Human Resources Development Survey (WB, 1993/94) found that
Government health centres were the main choice for out-patient care for the poorest. Approximately
70% of the sick individuals in the poorest 20% of households sought treatment firstly at government
health facilities. Furthermore, a more recent study confirmed that the poorest 20% of households
depended on government health centres and dispensaries twice as often as the richest 20%. It was
also found that in terms of in-patient care, wealthier individuals were more often likely to use
government hospitals and consume a greater relative share of all services than the poor (MOH/SDC,
2001). This seems to point to an unequal access to in-patient care for the poorest people. The Policy
and Service Satisfaction Survey (PSSS) 2003 confirms that this trend is still there. In 2003, two-third of
the rural households used government dispensaries and health centres for most treatment and only
31 Assuming that every person in the catchment population made one visit to the main hospital during the year
2000 and made a user fee contribution. The average fee for this visit was calculated to allow for comparison
(MOH/DFID 2002:39). From the available data it couldn’t be established whether fully exempted clients were
included in the average figures.
Equity Implications of Health Sector User Fees in Tanzania 21