equity implications of health sector user fees in tanzania

An indication of actual charges and additional costs to be paid by people in public PHC facilities is
provided in Table 6.1. The table shows that the additional costs to be paid can be even 15 to 80 times
more (or higher) than the formal fee implies! Poor people in a Lushoto health facility paid for an
episode of illness on average 80% for drugs and other fees, 10% on transport, food and
accommodation and 10% on informal charges (Mamdami, 2003). In the PSSS, people expressed
views on improvements and detoriation of costs and services. While 19% thought that the cost of
treatment had declined, 39% thought it had increased. While the availability of drugs increased for
nearly 30%, it deteriorated for 23% of the respondents (PSSS 2003:24-27, TzPPA 2003:97-98, SDC
2003:31-33, Mamdami 2003:8-10; Msuya, 2003; Munga, 2003; Khan, 2003; Ewald et al, 2004).
People’s ability to pay is not only determined by treatment costs but also depends on inflexible
payment modalities. Traditional healers are in that sense much more flexible than health facilities
(Muela et al 2000:301). It has been estimated that in hospitals and dispensaries, 70% and 40% of the
clients respectively, have difficulty to make the full payment for health services provided (Dercon
2000:56).
Coping mechanisms
The Tanzania Participatory Poverty Assessment (TzPPA 2003) provides a bleak overview of how poor
people cope with the inability to afford the user fee charges (see table 6.2).
Table 6.2: Coping mechanisms related to inability to pay user fee charges
� In 2001, a survey reported that 58.7% felt that
they should have consulted a health care
provider but did not do so because it was too
expensive.
� The Tshs 500/ fee for consultation is beyond
the meagre means of people, especially for
women and children who lack decisionmaking
power over the expenditure of
�
household assets.
Substantial treatment causes even a bigger
problem.
� People are forced to bribe (especially in
dispensaries and clinics) as a pre-condition to
receiving services. The official charges
constitute just one part of what is really paid.
The official fee can be 35% of the total costs
while the bribe can constitute 65% of the total
costs (based on available figures).
Source: TzPPA 2003: 97-98
� People cope with a disease, malnutrition or injury by
learning to live with even less by cutting back on
essential costs as medication, food and clean water.
� In order to pay people resort to desperate measures.
(reduce eating, selling of productive assets, taking out
a loan). This can lead to a poverty trap which can not
be escaped without external assistance.
� People resort to self-diagnosis and medicate traditional
or commercial remedies.
� Stigmatising diseases such as sexually transmitted
infections, HIV and AIDS fistulae, incontinence, and
disabilities often lead to humiliation, abuse, neglect and
social exclusion. This contributes to the inability to work
for an extended period of time. Combined with inability
to pay user fees often contributes to seeking delayed
treatment which becomes more costly.
Poverty-ill health circle
Many households have been directly impoverished by illness (SDC, 2003:1). The poverty-ill health
circle includes different phases; (1) People in poor households are more likely the others to become ill,
(2) When illness strikes, poor households lose the labour power of family members, (3) Many poor
households are forced to cope by selling off productive assets while social exclusion makes the
outcomes uncertain, and (4) The loss of productive assets and skills contributes to long-term poverty.
This limits the capacity of poor households to safeguard their health. This process has become visible
among people who have become affected by HIV/AIDS in Tanzania. Financing the drugs needed for
the treatment of opportunistic infections can devastate household resources because of the high costs
and recurrent nature of the illness (a single course of drugs may cost between Tshs 26,000-Tshs
40,000). People with HIV/AIDS are supposed to be exempted from cost sharing in public health care
facilities but this rarely occurs in practice (TzPPA 2003:97-98).
6.3 Findings from Kagera Region
Summary of critical issues
The study team carried out data collection in Kagera Region. The findings have been included in the
Technical Paper Part 6. In Kagera Region, people systematically indicate that they cannot afford to
pay the current user fees and that they have, as a consequence, to resort to alternative and even
humiliating strategies in order to obtain at least some kind of health service. On average this is the
case for 30% of the population in Kagera Region. The majority of the households (74%) do not have
access to a health facility, while the costs of transport to a health facility are considered as one of the
Equity Implications of Health Sector User Fees in Tanzania 23