equity implications of health sector user fees in tanzania

14% resorted to private (non-profit and profit) in first instance. In urban areas a similar trend was
observed (PSSS 2003:24).
Use of income from user fees
Documents do not reflect a differentiated and representative overview of the use of user fee income
per level for public dispensaries and health centres. It is therefore difficult to come to conclusions
regarding the actual use of the income of user fees by health staff working in public dispensaries and
health centres and the contribution of user fees to improved quality of health services. Detailed costing
studies (HERA 1999:74-129) looked in particular at the supply side rather than at the demand side of
the health services. However, due to the lack of transparency in the management of the district health
budget, it was not possible to obtain a good insight into the actual use of the health budget at PHC
facility level (In 1999, the health centres had not introduced cost recovery yet). The Health and
Education Financial Tracking Study (1999) found that government facilities which did charge user fees
did not retain them; collections were deposited by the DMO into the Health Services Fund Account
which is mainly used to purchase medical supplies for the District Hospital (and not the PHC facilities).
The study also found that the distribution of medical supplies benefited hospitals more than health
centres and dispensaries. Equity criteria for the distribution of available resources to the PHC level
were not followed systematically. A study in 2000 found that Government-run PHC facilities appeared
to suffer from severe shortages of antibiotics, antacids and anti-diarrhoeal drugs. The study confirmed
findings of earlier studies that allocations of supplies did not appear to be closely related to the patient
attendance and activities of the health facilities (MOH/SDC 2001).
In addition, it was very difficult to find evidence whether (1) increased availability of drugs is in fact a
result of user fees at different levels and (2) user fees themselves have contributed to increased
ownership and accountability of health workers. The overall impression is that availability of drugs is
more related to the allocations from the National Resource envelope than to income from the user fee
collection.
6.2 Consequences of user fee charges for poor and vulnerable people
Critical issues
The introduction of cost sharing in 1993/4 into the public health care system has put professional
health care beyond the reach of many (TzPPA 2003:97-98). Critical issues for poor people have been
highlighted in various studies. A prevailing view is that the introduction of the user fees has
disproportionately affected the use of services by the poor and vulnerable groups and constitutes a
barrier for the poor. This is often not well reflected in studies reflecting on the positive results of the
user fees, since available data fail to capture the experiences of people who fail to access care in
health facilities (Mamdani 2003:3-7, Dercon 2000:19). In the PSSS 2003, the cost of health treatment
was reported as the third most acute household problem, affecting over 50% of all households. Dar es
Salaam households complained more about the costs than those in other urban areas and rural areas.
Time and distance to the health facility constitute a major problem for one-third of rural households
and for less then one-fifth in urban settings. People reported to live even 45 km. from a health centre.
Distance, poor roads, the lack of suitable transport for the sick and persons with disabilities is the
second most cited obstacle to health care. In the last ten years the mean distance to primary health
facilities decreased from 4.4 to 3.9 km. However, nearly a half million households remain more then
20 km. from the nearest health facility. The real distance is often far greater if treatment is limited by
the quality of the nearby services (e.g. poorly trained staff, ill-equipped facilities, lack of
pharmaceuticals). The availability of drugs was reported as a major problem by nearly two-fifths of the
households and one-third complained about the long waiting time before they received assistance.
Female headed households identified these problems slightly more often than male-headed
households.
Nearly three-quarters of the respondents thought that the ability of people to pay for health services
had deteriorated during the last five years. Only less than 10% thought that this ability had improved.
Two-fifths of the respondents reported that they knew people who had been refused treatment
because of their inability to pay, especially for drugs and supplies. In Dodoma, 75% of the
respondents reported that they had been refused treatment because they could not pay the required
charges. Female headed households reported this constraint more often than men. A quarter of the
respondents reported unofficial payments to health workers. This was particular common in Dar es
Salaam. In urban areas, more men reported this constraint while in rural areas this was the reverse.
Equity Implications of Health Sector User Fees in Tanzania 22