equity implications of health sector user fees in tanzania

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on the access to health services for poor people. It has been estimated that in some areas poor people and specific categories (e.g. women, orphans, disabled) may constitute 30-40% of a District population. If Tanzania is truly committed to poverty reduction, as articulated in its PRS, it will be crucial to include effective pro-poor health financing strategies in the next PRSP. This will without doubt lessen the daily burdens and concerns of poor people. Equity Implications of Health Sector User Fees in Tanzania 34
VII CONCLUSIONS Poverty and health More than half of the population (17,500,000 people) in Tanzania lives below the poverty line. As many as 40% lives in abject poverty. Health indicators reflect that the since 1990, life expectancy has reduced; Infant Mortality Rates, Under 5 Mortality Rates, prevalence of child malnutrition and prevalence of HIV among women are stagnant; and that the number of births attended by skilled health staff has declined. Many Tanzanian households are affected by ill-health. Patients with HIV/AIDS related illnesses occupy approximately 50% of the hospital beds. HIV/AIDS, gender, urbanrural disparities and poverty strongly affect positive health outcomes. The immunisation rate of underfive children in the poorest 20% of the households is 25% lower than in the wealthiest 20% and stunting among the children in the poorest households is 22% higher. Only 27% of births in the poorest quintile are attended by a medically trained person compared to 81% in the wealthiest quintile. There is an urgent need to undertake appropriate measures in order to reverse the impact of poverty on the health status of the poor. PRSP While the PRSP is the document to design such measures and to address poverty and health related issues, it must be concluded that this is not adequately taken up yet. The PRSP takes a pro-poor approach in some areas, but does not sufficiently discuss the difficulties of achieving the set health targets in the poorest regions and among the poorest population groups. The PRSP and progress reports indicate a lack of country-specific, poverty-related health data. They do not discuss financial and non-financial barriers for the poor to access health services, they do not sufficiently report on the impact of user fees, and they fail to propose measures to adequately protect the poor against the possible adverse impacts of user fees, such as exclusion or reduced access. It is concluded that the PRSP is not yet sufficiently analytical and evidence-based in the formulation of its health and poverty reduction strategies, and as a result fails to adequately address the negative impact of user fees. Health sector strategies It is concluded that Tanzania has come a long way with the implementation of its health sector strategies. Since the 1990s, Health Sector Reforms and SWAp have been put in place to ensure well coordinated, joint funding mechanisms and performance monitoring systems for the public health sector. This has generated a wealth of information and valuable insight in the progress of the health sector. Health delivery network Health services in Tanzania are provided by the public sector, the private non-profit sector and the private for profit sector. This substantial network of facilities does not imply that people have equal and adequate access to quality health services. Quality of care is severely affected by the underdistribution of qualified staff to the remote and rural areas. There is an absolute gap of 20,000 full time health workers. It expected that this will triple to 60,000 in 2015. It can be concluded that improved quality of health services cannot be achieved if no adequate measures are taken. It is evident given the current situation that the PRS and MDG objectives cannot be achieved. Public health spending and pro-poor initiatives Tanzania has undertaken important measures to strengthen its pro-poor financing in the health sector. Positive developments include an increase in OC expenditure (e.g. medical supplies and drugs) for the MOH administration, for hospitals, for preventive services and for the total government recurrent expenditure. The increased distribution of allocations to local councils and the overall block grants for health to LGA level (almost 20% increase in FY04) shows evidence of the government’s commitment to devolution. An important strategy is the new Equitable Resource Allocation Formula (ERAF) which aims to redirect resources towards the poor. This indicates that the government is undertaking serious pro-poor efforts. Public health spending and concerning developments However, given the sizeable financing gap, it is doubtful whether the formulated health strategies can be achieved and the quality of health services can be improved. Under-expenditure has been identified as a major constraint and available funds do not always reach the intended beneficiaries. Widespread leakages of OC funds include (1) fewer allocations of funds to dispensaries and health centres than planned, and (2) a lack of transparency regarding the disbursements and allocation of Equity Implications of Health Sector User Fees in Tanzania 35
Page 1 and 2: C R Y S T A L EQUITY IMPLICATIONS O
Page 3 and 4: TABLE OF CONTENT ABBREVIATIONS ....
Page 5 and 6: ABBREVIATIONS AIDS Acquired Immune
Page 7 and 8: EXECUTIVE SUMMARY 1. Background Ear
Page 9 and 10: Tanzania has opted for a system of
Page 11 and 12: ACKNOWLEDGEMENT Many resource perso
Page 13 and 14: I INTRODUCTION 1.1 Background to th
Page 15 and 16: II LITERATURE REVIEW 2.1 Introducti
Page 17 and 18: have been highlighted in Technical
Page 19 and 20: met with donor support. After the a
Page 21 and 22: III POVERTY AND HEALTH IN TANZANIA
Page 23 and 24: diseases, (3) reducing malnutrition
Page 25 and 26: VI HEALTH SECTOR STRATEGIES TANZANI
Page 27 and 28: Pro-poor observations Tanzania has
Page 29 and 30: V COST SHARING STRATEGIES TANZANIA
Page 31 and 32: eported income proportion for the h
Page 33 and 34: VI IMPACT OF USER FEES IN TANZANIA
Page 35 and 36: An indication of actual charges and
Page 37 and 38: Table 6.3: Critical observations re
Page 39 and 40: All in all, there is limited eviden
Page 41 and 42: User fee policy Stakeholders mostly
Page 43 and 44: persons suggested to design a polic
Page 45: eneficiaries such as identity numbe
Page 49 and 50: Importance of the public PHC facili
Page 51 and 52: � In the absence of effective per
Page 53 and 54: LIST OF CONSULTED DOCUMENTS 50 Year
Page 55 and 56: Gilson, L. 1997. ‘The Lessons of
Page 57 and 58: Ministry of Health. 2003. Assessmen
Page 59 and 60: Schwerzel, P. 2001. Evaluation Repo
Page 61 and 62: World Bank. 2000. Poverty Reduction
Page 63: TECHNICAL PAPER
Page 66 and 67: 2. Groups with most regressive outc
Page 68 and 69: Although the primary purpose is to
Page 70 and 71: Technical Paper 6
Page 72 and 73: Health Sector Reforms: Strategic Pl
Page 76 and 77: Elements of the Community Health Fu
Page 78 and 79: stems from the rapid increase in de
Page 82 and 83: Type of service Clarifications Refe
Page 84 and 85: Charges in the public and private h
Page 86 and 87: � Implementation of fees at the l
Page 88 and 89: - Enhance the accessibility of serv
Page 92 and 93: Critical factors that hamper access
Page 94 and 95: An exploratory study 11 in Kagera R
Page 96 and 97:
Table TP 15 Views of 4 orphans towa
Page 98 and 99:
this way the health centre prevents
Page 100 and 101:
dispensaries. That is where most of
Page 103 and 104:
ANNEX 1 TERMS OF REFERENCE Equity I
Page 105 and 106:
� Access to services for the poor
Page 107 and 108:
ANNEX 2 DATA MATRIX FOR CATEGORISAT
Page 109 and 110:
(These are the key questions in the
Page 111 and 112:
ANNEX 3 GUIDELINES FOR DATA COLLECT
Page 113 and 114:
� Can you mention negative experi
Page 115 and 116:
� Which groups are exempted from
Page 117 and 118:
ANNEX 4 TOOL FOR ANALYSIS OF POVERT
Page 119 and 120:
c.3 User fees 19. Does the strategy
Page 121 and 122:
ANNEX 5 TANZANIA COUNTRY PROFILE 1.
Page 123 and 124:
2. Tanzania Millennium Goals Countr
Page 125 and 126:
ANNEX 6 RESOURCE PERSONS Name of Re
Page 127 and 128:
ANNEX 7 ITINERARIES 1. Itinerary Pa
Page 129 and 130:
03-04-2004 � Continued desk study
Page 131:
ANNEX 8 MAP OF TANZANIA Equity Impl
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