equity implications of health sector user fees in tanzania

amounts than the male respondents. It was found that user fees may result in lower utilization of
services by women including institutional delivery care. This is supported by the declining trends in
delivery care utilization in Tanzania between 1992 and 1999 following the introduction of user fees in
higher-level facilities in 1993. 34 Similar to declining institutional delivery observed among poor women
after the introduction of user fees in higher level facilities, adverse effects might also be observed in
primary health care for the poor on the introduction of CHFs and user fees in lower-levels facilities,
unless accompanied by effective exemption and waiver policies. The elderly population may also be
more adversely affected by the implementation of (uniform) user fees. Almost 17% of respondents
older than 46 years were not willing to pay anything for a health care visit.
The need for effective exemption policies for disadvantaged groups in Tanzania is evident from the
study. The authors conclude that (uniform) user fees can be regressive in terms of disproportionally
greater negative effects on utilization of health care by the poor compared to the rich. The findings of
this study are relevant to the ongoing efforts of the Tanzanian government to introduce cost-sharing in
lower-level facilities.
Impact of exemption and waivers
The impact of exemption and waivers in Tanzania clearly is an under-researched area. The study by
Msambichaka et al (2003) in that sense is an important study. The Msambichaka study reflects that a
poor performance or a negative growth in revenue collection is related to the number of exemptions
and waivers granted by a hospital. The growth in exemptions and waivers pull down the revenue
collection. It was also found that the registration of exemptions and waivers does not clearly appear in
the statistics and can be mixed up. It was found that waivers (e.g. for accidents) could be re-classified
into exemptions in order to reduce the number of waivers in the statistics. There was evidence that
waivers constitute an insignificant proportion of the total exemptions. This might be done as a strategy
to cover mis-use of the system and raise the volume of revenue collections in the statistics. This
implies that the data on hospital revenue collection can be flawed by inadequate registration of the
exemption and waiver system. It also implies that the hospitals are not eager to face a down-ward
pressure on their budgets.
The hospitals included in the study indicated that many patients apply for an exemption (at the same
time this can also mean a waiver, since the terms are often mixed up) and indicated that the
administration procedures are in itself not difficult to process. Hospital statistics indicated that most
exemptions were provided as statutory exemptions (following the guidelines) to children under five
years and women. Hospitals confirmed that (1) exemptions were provided to those who qualified but
did not always need it the most and (2) waivers did not target the poor and emergency cases as it
should be done. The study reflects that the processing of exemption and waiver systems is not user
friendly but cumbersome and bureaucratic. The study emphasised that exemptions and waivers are
socially justified irrespective of the revenue impact on cost sharing. The study recommended that
there is a need to retain the exemptions and waivers in hospitals but emphasised that the procedures
should become more simplified, user friendly, applicant friendly and time efficient. At the same time
incentives should be designed with a three-fold purpose; (1) to reinforce collection of revenue, (2)
proper expenditure and (3) effective implementation of the policy for exemptions and waivers. The loss
of revenue should be compensated by government resources. The procedures should also target
better the entitled beneficiaries and the poorest households since the procedures and entitlements are
not well known (Msambichaka et al 2003:13-29).
The study of Mamdani (2003) confirms the findings above but also cites other studies. The study
emphasises that there are examples of providing exemptions and waivers to vulnerable and poor
people by the FBOs and the rural government dispensaries and health centres. They continue to
serve as a safety net for the poorest people. The study, however, also points out that there is
substantial evidence of exclusion of patients who are not able to pay a formal fee or a bribe.
Respondents indicated that they did not use or attempt to use the waiver system. Many people simply
do not believe that as a poor person they are entitled and will be granted a waiver. For this reason
poor people refrain to go government facilities but try to obtain a partial waiver or partial treatment in
FBO facilities. Those who cannot pay simply stay at home and remain untreated.
34 The decline being more prominent among the poorest quintile of women (between 1992 and 1999 the
proportion of deliveries in the public facilities declined from 36% to 23% among women in the poorest quintile).
Equity Implications of Health Sector User Fees in Tanzania 26