equity implications of health sector user fees in tanzania

e part of a wider health care financing strategy rather than as central or only mechanism for
addressing resource constraints.
3. How to enhance the impact of user fees on their objectives? User fees should be: (1) part of a
broader health sector policy, (2) initiated within a coherent financing framework, (3) supported by
complementary government policies that promote sustainability and address underlying health
system weaknesses, and (4) built on various aspects of contextual support.
4. How to strengthen the process of implementation? Addressing the known problems of effective
user fee policy implementation requires: (1) consideration of the overall process of policy
development and implementation, (2) consideration of contextual factors, and (3) comprehensive
rather than selective processes of reform. Possible stages in such a process are described in
Technical Paper Part 5. Key strategies include: (1) advocacy before, during and after
implementation, (2) information strategies, (3) quality improvements prior to implementation, (4)
involvement of a wide range of actors, and (5) gradual and differentiated (at different levels)
implementation. Necessary conditions are: (1) strong and consistent leadership of Ministry of
Health, (2) capturing and use of relevant information, and (3) development and maintenance of
consensus.
6.7.2 Exemption and waiver systems
Guidelines for the design of successful user fee-waiver systems
Based on the analysis of various country studies, Bitran and Giedion (2003) formulated a range of
practical guidelines with the purpose to contribute to the design of successful user-fee waiver systems.
Countries that carefully designed and implemented their waiver systems have had much greater
success in terms of benefits incidence than those countries that took a more improvised approach.
The key to successful user-fee waiver systems for the poor in some countries – Thailand and
Indonesia – included (1) timely compensation to providers for revenue forgone from granting
exemptions, (2) widespread dissemination of information to potential beneficiaries about waiver
availability and procedures, (3) non-fee support to poor patients for costs of food and transportation
(as in Cambodia), and (4) clear criteria for the granting of waivers (Bitran et al, 2003). The following
guidelines are recommended:
� An explicit national policy on waivers and exemptions should be in place, which includes
guidelines for facilities, clear definitions of target beneficiaries and identification criteria that are
easily verifiable. The use of the income criterion alone for eligibility determination is questioned.
Case information points to a need to complement the income criterion with other information, or to
use other, more observable poverty proxies instead. The poverty definition ought to respond to
local circumstances and must be adapted to the specific cultural context.
� Key to the success of waivers and exemptions systems is the sufficient and timely financial
compensation of providers (instead of expecting them to absorb the cost). It is unreasonable to
expect that underpaid health staff that are responsible for, and have the ability to charge user
fees, will act in accordance with general equity principles by providing appropriate levels of
exemptions. A well-performing system of waivers and exemptions in government health facilities
must be in harmony with institutional and individual staff objectives. More specifically, government
funds or external funding from donors or lenders are required to grant providers with the
appropriate and minimum financial incentive to exempt the poor.
� Compensated user-fee revenue should reach health facilities promptly (timeliness of
compensation). Where compensation exists, it must be timely; otherwise the cost of delayed
reimbursement may be transferred by the provider to the poor, in the form of higher fees or lower
(or fewer) exemptions. Policies seeking to improve the protection of the poor should therefore
seek to streamline any bureaucracy involved in the reimbursement of facilities for exemptions
granted. Reimbursement procedures may be timelier in various ways (e.g. the regular allocation of
compensation funds from the central level to regional health authorities, or to regional funds, may
make compensation more opportune and predictable; or, in the absence of a decentralization
framework, monthly budgets sent from the central level to facilities may include an “exemptions
allowance” equal to the monthly target for that facility, with any (relatively smaller) adjustments for
differences between actual and budgeted exemptions being made later).
� In the absence of effective performance monitoring and evaluation systems, it is not possible to
measure performance of waivers and exemptions and to take any required corrective measures.
Regular monitoring of pro-poor protection systems should at a minimum, through routine facility
recording and via periodic household surveys: (1) Record exemptions and waivers granted, (2)
When using individual targeting, establish a data base containing basic information on
Equity Implications of Health Sector User Fees in Tanzania 32