equity implications of health sector user fees in tanzania

User fee policy
Stakeholders mostly recommended a phased approach to introducing user fees, starting with the
higher levels of health care and gradually going down to PHC levels. As such, they seem to agree with
the approach taken by the Tanzanian government. They did explicitly note, however, that the
Tanzanian approach has created many loopholes for excluding the poor from using health care. The
present user fee policy, the exemptions in particular, tends to benefit the better off more than the poor
and vulnerable people. Regarding whether it is reasonable to abolish fees, most stakeholders shared
the view that there is a need to strengthen exemption and waiver mechanisms for protecting the poor
rather than abolishing fees. The following strategies were mentioned:
� Improving accountability among health workers, the primary implementers of the user fee policy.
� Improving transparency to all stakeholders, i.e. collect and disseminate information on what is
actually collected, how is it being spent, how the exemption system operates, and what the
exemption criteria are (these should be clear and unambiguous).
� Making community members responsible for deciding who is eligible for exemptions instead of
relying on professional, technical criteria.
� Establishing a well-targeted fee structure and insurance system in line with the exemption system.
Poverty Reduction Strategy
Most resource persons recommended that in the second PRS, the Tanzanian government should
further strengthen its commitment to increased funding to the health and education sectors, so as to
create a sustainable infrastructure for improving people’s health and education levels which are
important tools in the fight against poverty.
6.6.2 Ministry of Health views
The MOH resource persons indicated that the first PRS did not sufficiently involve poor people in the
process and had not been as successful as expected because of a technocratic top-down approach. It
was felt that even at district level there was a disconnection with the priorities of communities. The
priorities for poor people were for example not sufficiently reflected in district council plans. However,
although shortcomings in the PRS process were acknowledged, the MOH resource persons
unanimously supported Tanzania’s present user fee policy. They pointed in particular to positive
impacts in terms of poverty reduction, quality improvements (particularly for drug supplies), revenue
generation, the reduction of informal charges and increased consumer’s choice. They qualified the
design and intention of the user fee policy as pro-poor because those who cannot afford to pay are
under special exemptions arrangements.
Despite their support to the user fee policy, most resource persons, some more explicit than others,
recognized that the present exemption policy is not functional. Corruption, mismanagement of funds
and inconsistent ways of implementing exemptions have all contributed to exclusion and further
impoverishment of the poor, the intended primary beneficiaries. The need to follow MOH guidelines as
a strategy to address these problems and the importance of improving health workers morale were
emphasised.
Resource persons differed in their opinions on the best cost sharing scenario for Tanzania. One
resource person considered the Community Health Fund “the saviour to not only the poor, but to the
overall health system” and preferred the continuation of the present situation, in which fees are
charged in the hospitals and a binding CHF is implemented at lower level health facilities. If was felt
that the severe delay of the introduction of CHFs in other districts was related to the time consuming
process for CHF registration at district level (establishment of District Health Boards, need for legal
constitution) and the limited follow-up of districts to follow-up with the PORALG the CHF application
and establishment of the compulsory by law for binding citizen to the CHF for each district.
Another resource person felt that the CHF, complemented with other health financing mechanisms
such as user fees taxation and NHIF, would be the best solution to address the health needs of the
poor, and to help Tanzania rescue those resources that were wasted under previous policies. In
addition, this resource person mentioned the need to generate domestic instead of donor resources to
bridge the health financing gap. A third resource person, however, proposed to charge fees at all
levels (further extension), while improving the existing exemption policies: “This is a pro-poor approach
of financing health services because those who are not ready to pay for health services at the point of
Equity Implications of Health Sector User Fees in Tanzania 29