equity implications of health sector user fees in tanzania

9. Adequacy of revenue generated. Fees do not appear to generate adequate revenue or to be
associated with the resource allocations necessary to enable substantial, sustained improvements
in health care for the poor (various authors; in Gilson, 1997).
10. Management. While the effects to date of user fees on the poor appear almost universally
negative, in virtually all cases this has been the result of weak design, planning and
implementation (Bennet and Gilson, 2001; Gilson, 1997). Experience from a few small-scale user
fees schemes with heavy technical assistance inputs and evaluation components suggests that if
appropriately designed and implemented, user fees may deliver benefits to the poor (Bennet &
Gilson, 2001; see also Ridde, 2003).
11. Transparency. The way services are priced within and across facilities are difficult for potential
patients to assess. A way of promoting transparency and limiting ‘leakage’ in fee collection is to
keep accurate records of amounts charged and issue receipts. ‘Under-receipting’ may indicate
under-the-table payments requested of patients. Transparency can also be increased through
advertisement of fees within the premises of the facility, preferably at the point of fee collection
(Nyonator and Kutzin, 1999).
12. Increasing voice. In general, neither those responsible for implementation nor the community have
had much involvement in the design of systems that most immediately impact on them (Bennet &
Gilson, 2001). This indicates that the contribution of cost-sharing/user fees to increasing the voice
of the users of health care has been limited.
Exemption and Waiver systems
Exemptions are used to automatically provide free care because the patient has the characteristic of
being targeted. Exemptions can e.g. be provided for certain kinds of health services. 4 A waiver is used
to reduce or eliminate fees for the poor, based on an assessment of their ability to pay. As such,
waivers relate to direct targeting. The problems commonly associated with these mechanisms are
under coverage and leakage. Under coverage occurs when the poor do not receive the intended
benefits, because they are by error categorized as non-poor or because they must still pay the fee
despite their waiver. Leakage occurs when the non-poor receive benefits intended for the poor.
(Grosh, 1994; in Newbrander & Sacca, 1996). Kivumbi and Kintu (2002) mention an additional safety
net form, namely the provision of credits. In this case, patients willing to pay at a later time receive
treatment on credit.
Best practises of providing waivers to the poor were found in; (1) Thailand, where 80% of the
population living below the national poverty line had been given a free health card through a pro-poor
target system which included geographic targeting combined with income testing and group targeting;
(2) Indonesia where in some provinces 89% of all poor families received a waiver through a pro-poor
target system that included geographic and individual targeting combined with uniform poverty
proxies; and (3) in Chile where the coverage of the poor population was 90% as a result of? a
targeting system that included income thresholds, type of services and other poverty proxies. The
lower level services were free. The leakages were high, meaning that non-poor were also included.
The system in Chile was found to be the best practise in promoting equity in access and in financing
(Bitran et al, 2003).
Community Health Fund
There is great variety in CHF design, some offering specific health service packages and others
excluding categories of health services. CHFs are prepaid schemes, where a fixed annual
membership fee entitles households (or individual patients) to free health care, while non-members
have to pay user fees on a fee-for-service basis. Membership fees are commonly set according to the
risk faced by the average community member. This means that there is no distinction in premiums
between high and low risk groups. Unlike social health insurance schemes, enrolment is generally
voluntary and not linked to employment status (Bennet & Gilson, 2001 and Bonu, 2003).
4 In Uganda, categories of patients to be exempted include children under 5 years of age, patients suffering from
chronic diseases such as AIDS, tuberculosis, cancer; promotive and preventive services such as immunization,
ante- and postnatal care, and family planning services; (Kivumbi & Kintu, 2002).
Technical Paper 3