equity implications of health sector user fees in tanzania

persons suggested to design a policy that ensures that poor people are not priced out of the health
care system, combined with a policy to allocate more funds to a basic package of quality health
services that can be accessed by especially the poor.
In relation to the next PRS, the respondents were of the opinion that the position that user fees, CHF
and alternative complementary financing mechanisms should be taken on board and should be
effectively strengthened as part of the long-term strategy of using the health sector as a tool to fight
poverty. Mechanisms should be designed to ensure that the next PRS is implemented in a selective
manner, meaning that those who are able to pay do so and those unable to pay are actually
exempted. The respondents did not find the achievements of the PRS over the last three years
encouraging, particularly in relation to health. In their opinion, the health chapter had not been
adequately mainstreamed in the PRS process. It was felt that the government commitment to
financing health services is proportionally declining as compared to donor funding, which is increasing.
More in general, the PRS is largely donor-driven around specific project and programmes, which are
unfortunately not properly coordinated.
6.7 Lesson learned and policy recommendations from literature review
6.7.1 User fee systems
General key lessons
Over the past years, authors have summarized the lessons learned from the implementation of user
fee systems and various safety nets. The recommendations predominantly relate to strengthening
existing user fee systems. The study team has included detailed overviews of reference material in the
Technical Paper (Part 5). Bennet and Gilson (2001) have identified the following key lessons;
� It does not make sense to assess whether or not a single financing mechanism is pro-poor; such
an assessment must be carried out with respect to the complete mix of financing mechanisms and
their interaction with resource allocation approaches and organisational contexts.
� User fees and community-based health insurance are unlikely to be equitable or sustainable if
they are the prime source of health finance. In order to protect the interests of the poor they
should be viewed only as a means to ‘top-up’ other financing systems (such as tax revenues and
social health insurance).
� Although a financing system may in design be pro-poor, it is important to think about whether or
not it is feasible to implement this design. In practice political pressures may prevent shifts in
resource allocations to the poor, and limited government capacity may hinder the effective
implementation of exemption schemes to protect the poor, or may prevent the promised gains in
quality of care from actually materializing.
� Poor people’s access to health care is often constrained by low quality care, high transport costs,
long waiting times and inconvenient opening hours. Financial reforms, which deliver improvements
in these dimensions of quality at a moderate price, particularly in relation to hospital care, will
probably benefit the poor.
� The effective development and implementation of pro-poor financing policies is never a once-only
action, but always the result of a sustained approach that allows adaptation over time in response
to experience and changing circumstances. Within such an approach, it is essential that as much
attention is given to strategies that build and maintain support for the policies over time, as to
technical adaptations of policy design.
Inventory of lessons learned: four core sets.
In 1997, Gilson identified four core sets of lessons learned (see for the elaborate version Technical
Paper Part 5). They are still valid since other authors confirm this set and come up with similar
recommendations (also in more recent publications) (see e.g. Kipp et al, 2001; Nyonator & Kutzin,
1999; Newbrander & Sacca, 1996; Bennet & Gilson, 2001). Key questions and main lessons learned
are:
1. What are key bottlenecks to the effective implementation of user fees and safety nets? (1) Weak
design of user fee systems, (2) weak capacity for local level financial management and fee system
implementation, (3) weak supporting systems, and (4) contextual constraints.
2. Where and when to implement user fees? (1) Fee implementation should focus on the hospital
level and should be associated with risk-sharing mechanisms and exemptions, and (2) fees should
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