equity implications of health sector user fees in tanzania

� 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.
� Fee levels and income-eligibility thresholds need to be adjusted and updated periodically. There is
no single answer to who should be responsible for the exemption process, but those determining
eligibility should be aware of the selection criteria; be adequately trained; and be fully informed
about the constraints governing the waivers process. Providers need clear written guidelines
about how waivers and exemptions should work, with enough flexibility to allow for regional or
local variation if necessary. Several resources point to the central role of communities in this
process.
� The poor should not only be waived for user fees but also be reimbursed for their access costs to
health care beyond fees, such as transportation, lodging, food costs and opportunity cost.
� Under-coverage will be a constant problem when the poor do not know they are eligible for free or
subsidized care and when health facilities are not aware of whom to exempt or waive. Likewise,
the population should be informed about the existence of certain exempted services.
For Community Health Funds, both long- en short term recommendations have been identified. Key
recommendations include:
� There should be an affordable prepayment membership fee.
� The benefit package and entitlements should be attractive.
� There should be reimbursement to the CHF for exemptions provided to poor people.
� Procedures for record-keeping should be improved to ensure that funds are properly accounted
for and deposited. In addition, training should be provided to staff to ensure that they understand
the procedures.
� Overall education and promotion is needed to increase understanding of the benefits and
management of the CHF. More effort is required to involve district and community leaders in
promoting and managing the CHF.
� Implementation of an effective exemption policy is required to ensure that the poor are not
excluded from accessing services.
Scenarios and reflections
Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders
continue promoting and supporting user fees in the absence of effective exemption and waiver
systems. This does not correspond with the commitment to reducing poverty in Tanzania as
articulated in the PRS. Consequently, immediate political action is required. Looking at strategies for
improvement, it is clear that the results of the abolition of user fees for health and education in
Tanzania, South Africa and Uganda have been impressive. In Uganda, improvements have been
observed in terms of attendance, morbidity and mortality. There also is evidence that access to health
services for the poor has improved. As such, abolition can be considered as a pro-poor option to
reduce exclusion and self-exclusion among the poor and vulnerable. The studies illustrate, that the
abolition of fees needs to be combined with considerable efforts in other areas, such as changed
levels of funding (internally and externally), improvements in the allocation and disbursement of funds,
improved human resource development, improved incentive schemes for health workers and
improved quality of services. This indicates the importance of a broad, strong political support and
donor support.
When reviewing the stakeholders’ attitudes towards abolition of user fees, it seems that such support
seems presently lacking in Tanzania. However, the developments in Uganda and Kenya might have
created a momentum for Tanzania to re-think the current multiple risk pooling strategies in the context
of the PRS Review and to opt for more pro-poor health strategies. It should be noted that in the
current political situation strengthening the existing exemption and waiver systems seems to be the
most preferred scenario at this moment. Specific strategies for this have been described above.
However, in the light of all the constraints mentioned and in the context of positive developments in
Uganda and recent decisions taken in Kenya, the study team would like to recommend to include the
suspension of user fees at PHC level in the next PRS document for Tanzania as a real pro-poor health
strategy for Tanzania.
As noted by Walford (2001), the PRSPs and PRS processes provide an excellent opportunity to
facilitate changes in existing user fee policies and to improve their equity impact. PRS processes can
serve as a way to bring poverty up the national and health agenda. Furthermore, they can provide an
opportunity to re-open areas of health or budget policies where there is no pro-poor strategy in place.
Equity Implications of Health Sector User Fees in Tanzania 39