equity implications of health sector user fees in tanzania

� Combine low fees, age exemptions, and limited waives for primary and consultation services with
means testing for higher-cost inpatient services.
� Allocate more central funding to facilities in poorer areas to off-set the lower revenue they
generate through user fees.
� Focus on granting exemptions for the poor and vulnerable, such as the children of the poor.
� Protect the poor and prevent others from becoming poor.
To make user fee systems effective in protecting equity while raising revenue, several critical elements
must exist:
� Leaders must be committed to the principle of equity.
� Clear guidelines need to be established for implementing the user fee system and applying
exemption systems.
� Facilities must have the capacity to administer the system, exempt the poor, and correctly use the
collected fees to benefit the community and the poor.
� The public must have information about the user fee system, uses of fee collected, and eligibility
for exemptions.
� Facilities must be accountable to communities for the use of revenues raised.
General principles for the choice of fees and targeting mechanisms
� Use low fees or no fees for public health services.
� Relate fees to the costs of services.
� Vary fees according to ability to pay.
� Encourage medically necessary consultations (e.g. free or inexpensive doctor’s visits).
� Adapt means testing to the situation.
� Inform patients about fees.
� Use all-inclusive (bundled) fees only when all services are available.
� Provide emergency services for free; collect fees later from those who can afford to pay.
Means testing procedures
� Use documentary evidence.
� Means-test in the facility.
� Keep administrative costs low.
� Discourage waivers.
� Determine who recommends a waiver.
� Determine who approves a waiver.
� Use standard questionnaires.
� Use means testing for high-priced services.
� Set policies about partial payment and negotiate fees in advance.
� Determine the duration of waiver certification.
� Consider referral waivers.
� Control credit.
Implementing new fees and targeting mechanisms
� Introduce acceptable fee types first.
� Set fees low.
� Reduce exemptions over time.
� Gradually establish more stringent means testing.
� Introduce fees gradually, beginning with the highest-level-facilities.
Management
� Set targets.
� Conduct continuous monitoring.
� Account for exemptions and waivers.
� Review patient characteristics.
Technical Paper 25