equity implications of health sector user fees in tanzania

More documents

Recommendations

Info

� Implementation of fees at the lowest, poorest levels within the system where little revenue can be generated. � Lack of co-ordination and fine-tuning between fee levels across the health system, with the potential to create perverse utilization levels (e.g. user fees at secondary levels are lower than at primary levels) and inequities (e.g. higher fee levels in poorer areas). 2. Poor capacity for local level financial management and fee system implementation � Lack of financial management skills throughout the health system, but especially at district or community level. � Lack of appropriate financial management information and audit systems. � Lack of information with which to target the poorest effectively through exemptions. � Limited local authority to take appropriate resource use decisions without reference to higher authorities. � Limited effectiveness in collecting fee revenue, undermining revenue generation rates and revenue use of quality improvements. � Lack of guidance on financial management and control practices, e.g. on who is eligible for exemptions; how to account for revenue generated; and on procedures for using revenue. � Failure to retain fee revenue locally, undermining the incentive to collect it and user it for local level quality improvements. � Total retention of revenue locally leading to limited redistribution of resources between geographical areas with different capacities to raise revenue. � No procedures that would allow the impact of policy implementation to be monitored. 3. Weak supporting systems � Poor quality public services which undermine the population's willingness to use services (e.g. drug shortages, unfriendly staff). � Inadequate human resource policies which do not promote or sustain staff morale. � Inadequate drug supply and distribution systems. � Operational inefficiencies within the health system which contribute to quality failures (e.g. drug wastage and abuse leading to shortages). � Limited funding for the supervision and support needed by the primary level. � Inadequate management information systems e.g. which do not allow resource use to be related to services provided. � Organizational structures which generate weak and conflicting lines of accountability both downward to community level, and upwards to technical supervisors. 4. Contextual constraints � The population's lack of experience in paying for public health services, which generates an unwillingness to pay for them, particularly when perceived quality is low. � Weak banking and communication systems, undermining local level financial management and the potential for support. � A variety of socio-cultural and political constraints at both local and national levels, that e.g. preclude consideration of the needs of the poor in decision making, allow richer groups to be incorrectly exempted (leakage) and prevent the reallocation of resources to primary health care that would most benefit the poorest. 2. Enhancing the impact of user fees on their objectives – lessons for policy design 1. Fee system design � Use a simple fee structure, linked to treatment received (e.g. prescription fee). � Set affordable price levels. � Use simply-to-apply exemption categories (e.g. characteristic targeting). � Ensure the price structure is advertised within health facilities. � Coordinate the price structure across health system levels. � Readjust prices periodically. � Ensure that some revenue is retained at the point of collection for use in quality improvements. � Establish guidelines and procedures to promote revenue use for perceived quality improvements. � Develop community mechanisms at primary levels. Technical Paper 22
2. Complementary government policies a. Financing policy framework � Maintenance of existing levels of government funding for health system as a whole. � Development of complementary risk-sharing financing mechanisms. � Establishment of resource reallocation mechanism favoring relatively under-resources geographical areas and more cost-effective services. � Promotion of community solidarity mechanisms which can assist the ultra-poor. � Development of community management mechanisms, which ensure accountability to community. b. Policies to support sustainability � An effective reward and discipline system for health staff, including training. � An effective drug procurement and supply system. � Effective management and clinical supervision and support for ‘local’ level (district or community). � Management-oriented information systems which allow monitoring by providing data on e.g. revenue collected, revenue use patterns. � The development of skills and systems to enable decentralization of resource use, control and management within wider system to appropriate level. � A supportive legal framework for fee/sustainability policies. 3. Contextual support � Institutional capacity within health system to provide support to local level decision makers. � Adequate leadership and advocacy skills within the health sector to develop political support for appropriate design and policy. � Wider institutional support (e.g. banking facilities; communication facilities). � Consumers’ willingness and ability to pay. � Professional ethics to counterbalance health workers’ responsiveness to financial incentives. 3. The process of implementation Stage 1 � Identifying problems likely to affect implementation of broad fee system design (e.g. poor quality of care, lack of willingness to pay, opposition from critical stakeholders. � Collecting baseline data by which to assess implementation impact and effectiveness (e.g. ability to pay data. Stage 2 � Review of the fee system design and careful planning to address, as far as possible, the expected problems of implementation. � Identifying factors constraining and facilitating effective implementation. � Developing strategies to offset potential constraints on implementation. Stage 3 � Implementation of steps to develop key prerequisites for effective implementation. � Initial implementation of fees. � Monitoring impact/effectiveness of fees, and the factors influencing impact. � Operational research to support implementation. Stage 4 1. Review and revision of fee implementation approach. 2. Next stage of implementation. 3. Further monitoring. 2. Bennet & Gilson, 2001 � What does it mean for a health financing system to be pro-poor? The most important dimensions are that the system should: - Ensure that contributions to the costs of health care are in proportion to different households (ability to pay). - Protect the poor (and the nearly poor) from the financial shocks associated with severe illness. Technical Paper 23
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 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 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 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
show all

equity implications of health sector user fees in tanzania

Create successful ePaper yourself

Delete template?

Save as template?