equity implications of health sector user fees in tanzania

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Although the primary purpose is to share the risk between individuals and to extend financial protection to members of the scheme, in practice different stakeholders have different perspectives on the objectives of the CBHI schemes. Three types of criteria (equity, financial sustainability and efficiency) are commonly used to assess health care financing schemes but in many cases there is no clear alignment between scheme-specific objectives and social ones. Mechanisms to promote individual scheme sustainability can conflict substantively with equity concerns. In practice, individual schemes may have to focus more on sustainability issues than equity issues (Bennet, 2004). CBHI schemes appear particularly appropriate for providing insurance coverage to persons with limited protection from other sources (e.g. not employed in the formal sector). They also seem particularly relevant to low-income countries where government revenue is limited and where there is extensive reliance upon out-out of-pocket payment. The WHO has recommended that out-of-pocket expenditures by poor communities should increasingly be channelled to ‘community financing’ schemes. Largely anecdotal evidence suggests that it is primarily the rural middle-class that joins the CBHI schemes. There is a concern about what happens to people who are not members of the schemes. Exclusion of the high-risk individuals from scheme membership will affect the sickest and probably the most vulnerable members of the population. Placing limitations on the benefit package will most likely reduce the level of effective protection provided against financial risk. It is assumed that people will prefer CBHI schemes that offer complementary risk protection 5 to that provided by the Government. Abolishment of user fees Experiences from the health sector in South Africa In South Africa, user fees for children aged under 6 years and pregnant women were removed in 1994, and in 1997 all user fees at all primary health care clinics were abolished. The intention of these policy changes was to improve access to health services for the poorest and previously disadvantaged communities. Wilkinson et al (2001) noted that little is known about the impact of removing user fees on the differential utilization of preventive and curative services. The authors found that the total number of consultations for curative care almost doubled, while the number of consultations for preventive services fell. It appeared that the removal of user fees encouraged and increased access to curative services, but subsequent clinic congestion and reduced consultation times may have discouraged some women from attending for antenatal care and from bringing their children for growth monitoring and immunization. It was felt that for this reason: (1) a slower, phased introduction could have avoided some of the reported adverse effects, and (2) governments should closely monitor the impact of such policy changes. 5 E.g. (1) the extent of co-payment (user fees) for government-subsidized services, (2) the extent of the benefit package or essential package, and (3) user perceptions of relative quality of care in public and private sectors. Technical Paper 4
PART 2 BACKGROUND INFORMATION TO CHAPTER 2 Background information on PRSP health related targets and their feasibility Table TP 1: PRSP health related targets and their feasibility Target Feasibility Target Feasibility � Reduce infant mortality rate from Unlikely to � Reduced prevalence of wasting Little progress 99 to 85 per 1,000 live births by 2003 reach (weight for height) from 7% to 2% � Reduce infant mortality rate to 50 Unlikely to � Contain sero-positive prevalence Very per 1,000 live births by 2010 and to reach rate in pregnant women from 5.5- challenging 20 by 2025 23% (1996) to 6-27% in 2010 target � Reduce under-five mortality per Unlikely to � Reduced maternal mortality rate Indicator not 1,000 from 158 to 127 by 2003 and reach from 529 to 450 per 100,000 by appropriate to to 79 by 2010 2003 and 265 by 2010 asses on shortterm, � Increase of children under 2 years Target � Increased coverage of births by Requires a immunised against measles and within trained personnel from 50% to radical change DPT from 71% to 85% in 2003 reach 80% in present trend � Malaria in-patient case fatality for Difficult to � Restored life expectancy to 52 Unlikely to under-five children decreased from calculate years by 2010 reach with 12.8% to 10% by 2003 and 8% b in HMIS of HIV/AIDS trend 2010 MOH � Reduced prevalence of stunting Little (height for age) reduced from 43% progress to 20% Source: Extracted from Poverty and Human Development Report 2002:104-105) Technical Paper 5
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C R Y S T A L EQUITY IMPLICATIONS O
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TABLE OF CONTENT ABBREVIATIONS ....
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ABBREVIATIONS AIDS Acquired Immune
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EXECUTIVE SUMMARY 1. Background Ear
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Tanzania has opted for a system of
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ACKNOWLEDGEMENT Many resource perso
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I INTRODUCTION 1.1 Background to th
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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 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
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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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