equity implications of health sector user fees in tanzania

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NPES National Poverty Eradication Strategy OC Other Charges OPD Out Patient Department PEDP Primary Education Development Program PER Public Expenditure Review PHC Primary Health Care PLWHA People Living with HIV and AIDS PORALG President’s Office, Regional Administration and Local Government POW Plan of Work PRS Poverty Reduction Strategy PRSP Poverty Reduction Strategy Paper R&AWG Research and Analysis Working Group RE Resource Envelope REPOA Research for Poverty Alleviation RMO Regional Medical Officer SCF Save the Children Fund SDC Swiss Agency for Development and Cooperation SIP Sector Improvement Programme SWAp Sector-Wide Approach TA Town Authorities TAS Tanzania Assistance Strategy TB Tuberculosis TC Town Council TEHIP Tanzania Essential Health Intervention Project TGNP Tanzania Gender Networking Project TOR Terms of Reference Tshs Tanzania Shillings TzPPA Tanzania Participatory Poverty Assessment U5MR Under Five Mortality Rate UNCESCR United Nations Committee on Economic, Social and Cultural Rights UNDP United Nations Development Programme UNECA United Nations Economic Commission for Africa UNICEF United Nations International Children’s Emergency Fund VA Voluntary Agencies VPO Vice President Office VSSC Village Social Service Commission WB World Bank WDC Ward Development Committee WDP Women’s Dignity Project WHC Ward Health Committee WHO World Health Organisation WTP Willingness to Pay Equity Implications of Health Sector User Fees in Tanzania iv
EXECUTIVE SUMMARY 1. Background Early 2004, Research for Poverty Alleviation (REPOA) commissioned ETC Crystal to examine the equity implications of health sector user fees in Tanzania, with particular reference to proposed and actual charges at dispensary and health centre level. This year, Tanzania will review its Poverty Reduction Strategy. With the findings of the user fee study, REPOA aims at making a valuable contribution to the review process and provide country-specific insight into one of the most debated issues in health financing. 2. Methodology The focus and design of the study was formulated in close cooperation with the Research and Analysis Working Group of REPOA. The strategies for data collection comprised: (1) a comprehensive literature analysis literature, (2) semi-structured interviews with resource persons from the government of Tanzania, multi- and bilateral donors, research institutes and NGOs in Dar Es Salaam, and (3) a case study in Kagera Region, including both document analysis and semi-structured interviews with resource persons from the MOH, NGOs, FBOs, health workers and health care consumers from vulnerable and poor population groups. The study team developed multiple tools for data collection and analysis including: (1) a data matrix for categorisation and identification of key issues, (2) guidelines for the interviews in Dar Es Salaam, (3) guidelines for data collection and interviews in Kagera Region, and (4) a tool for the analysis of poverty reduction strategy documents. A total number of 170 user fee-related documents were assessed, including those covering the experience from neighbouring countries. Seventy-nine resource persons participated in the study. 3. Main findings and recommendations 1. Resources generated by user fees and their use at hospital, district council and PHC levels. The study team found that reliable, transparent user fee income data for district, hospital and PHC level were difficult to obtain. Based on what information is available, the team concludes that revenues raised from user fees at the hospital level have been lower than what has been projected. Furthermore, the data reflect huge variations between facilities and a decline in the revenues from cost sharing. The reasons of the reported decline are unclear. The data reflecting the contribution of user fees and CHF to the health budget at district council level show huge variations as well. The reported user fee income proportion for the district health budget was on average 10.5%. The study team could not establish how the income from cost sharing and the CHF was re-distributed by the council to PHC facilities or priority areas. A worrying finding was that some councils did not spend all health resources in the health sector. The study team observes an urgent need for: (1) more accurate and comprehensive record keeping at local council level, and (2) more costing and tracking studies to obtain a better insight into cost sharing and expenditures and to adequately inform policy making. 2. Contribution of user fees and CHFs to the health resource envelope. The study team concludes that the national projections of the cost sharing schemes do not reflect an accurate picture, since the data are based on the inaccurate financial data received from the districts. It is likely that the actual and projected data on user fees, CHFs and HSF are underestimations of the real income collected at the different facility levels. This means that the MOH faces a loss of income that cannot be redistributed to the health sector. It also implies that people (both wealthy and poor) are likely pay more than what is officially reported. The actual potential and use of the non-reported user fees are not known. The total contribution of the cost sharing schemes (excluding NHIF) to the national health resource envelope for FY03/04 is 1.67 Billion Tshs. This equals a contribution of 0.6% to the overall budget for the health sector. In total, this is US$ 1.56 million. Given the size of the total health budget (US$ 260 million), it can be concluded that the officially reported user fees contribute a small proportion only. The actual revenue generated does not meet the initial expectations. 3. Contribution of revenues generated to improved services. The study team found limited positive evidence that user fees in Tanzania have in general achieved their original objectives of sustainability, drug availability, quality of care, equity and access for the poor. More specifically, Equity Implications of Health Sector User Fees in Tanzania v
Page 1 and 2: C R Y S T A L EQUITY IMPLICATIONS O
Page 3 and 4: TABLE OF CONTENT ABBREVIATIONS ....
Page 5: ABBREVIATIONS AIDS Acquired Immune
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 and 46: eneficiaries such as identity numbe
Page 47 and 48: VII CONCLUSIONS Poverty and health
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 74 and 75:
Technical Paper 10
Page 76 and 77:
Elements of the Community Health Fu
Page 78 and 79:
stems from the rapid increase in de
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Technical Paper 16
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Type of service Clarifications Refe
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Charges in the public and private h
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� Implementation of fees at the l
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- Enhance the accessibility of serv
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Technical Paper 26
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Critical factors that hamper access
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An exploratory study 11 in Kagera R
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Table TP 15 Views of 4 orphans towa
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this way the health centre prevents
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dispensaries. That is where most of
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ANNEX 1 TERMS OF REFERENCE Equity I
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� Access to services for the poor
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ANNEX 2 DATA MATRIX FOR CATEGORISAT
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(These are the key questions in the
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ANNEX 3 GUIDELINES FOR DATA COLLECT
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� Can you mention negative experi
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� Which groups are exempted from
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ANNEX 4 TOOL FOR ANALYSIS OF POVERT
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c.3 User fees 19. Does the strategy
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ANNEX 5 TANZANIA COUNTRY PROFILE 1.
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2. Tanzania Millennium Goals Countr
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ANNEX 6 RESOURCE PERSONS Name of Re
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ANNEX 7 ITINERARIES 1. Itinerary Pa
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03-04-2004 � Continued desk study
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ANNEX 8 MAP OF TANZANIA Equity Impl
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