equity implications of health sector user fees in tanzania

� In the hospitals special devices for persons with disabilities are not available; prosthesis calipers,
walking sticks, Braille, hearing aids, sunglasses (for albinos).
� Barriers to access services are related to poverty, perceptions of the attending health staff, and
absence of a government policy towards people with a disability.
Exemptions and waivers
The Social Welfare Officer (SWO) of Bukoba Regional Hospital is the person responsible for granting
an exemption or a waiver. In addition to this responsibility, he/she has also other duties in the hospital
(e.g. anaesthetics), taking care of referral of “dumped babies” to an orphanage, refer the “helpless”
and the “loitering” to a home care facility. The SWO felt that the exemption and waiver guidelines are
clear but cited a range of problems: (1) some people pretend that they are poor while they are not, (2)
rich people with chronic diseases prefer free treatment, (3) Government exemption and waiver cards
are not accepted in the mission hospitals even if one lives nearby a mission hospital, and (4) Kagera
Regional hospital is the only hospital where people can obtain an waiver. The official regulation is that
the exemption/waiver card is only for hospital services and is not applicable to PHC facilities. The
SWO expressed concern that if fees are to be introduced in health centres and dispensaries, the
health staff first will need training on the exemption and waiver procedures since this will be a new
procedure at PHC level. He felt that otherwise the system may be misused. At this stage, it is only the
Regional SWO who is authorized to provide an exemption/waiver card. There is no limit to how many
people can be given a waiver per day. On average 5-8 people receive a waiver per week. This is most
often the case for the in-patients and not for the out-patients. According to the SWO, nobody is turned
away because he/she cannot pay. Exemptions are given on weekdays by the Social Welfare Officer.
During the weekend, the attending doctor can indicate the need for a waiver. Usually the exemption is
given for the duration of one month. This can be renewed afterwards. The SWO indicated that there is
an increase of people requesting a waiver due to the improved sensitization on this.
The private (non-profit and for profit) sector in Kagera did not use an exemption of waiver system.
Private for profit clinics do not provide an exemption of waiver to patients (only in rare cases) and do
not participate in a CHF. They have not been invited to do so but would be willing to participate. Nonreligious
NGOs indicated that they felt forced to introduce user fees due (1) the reduction of external
funding and (2) the donor demands for increased sustainability of the programme. It was felt that this
had a negative impact on the poorest project beneficiaries. NGO did not follow an exemption and
waiver system either. It was found that the Catholic HFs did not have a formal exemption and waiver
policy in place. Payment of user fees in instalments was allowed and accommodated the poorest
groups. In some situations, a Congregation assisted the poor from private funds. The Catholic HFs
realized that the poorest people cannot afford their services but also needed to charge User Fees to
sustain their facilities. It was indicated that the poorest people were referred to the Government HFs in
case of prolonged and costly health services.
Not many people receive a waiver considering the poverty level in Kagera. This was confirmed by
resource persons. The general opinion is that poor and vulnerable people are not protected by the
existing exemption and waiver systems. Resource persons indicated that the elements of the
exemption and especially the waiver system are not clear. The waiver system is not well understood
and many people are not aware of its existence. Experiences of resource persons indicate that the
exemption and waiver system is not transparent. It is felt that the procedures are too bureaucratic and
should become more straightforward. It was emphasised that poor people who require a waiver often
do not receive it while big shots manage to get free or subsidized treatment. NGOs indicated that the
exemption and waiver procedures are stigmatizing the clients and that the Social Welfare staff are not
helpful to poor people. It was emphasised that the identification of people who cannot pay for health
services was difficult. Resource persons felt that the people who are best placed to assess the ability
of poor people to pay and the need for a waiver are; Social Welfare Officers, Health Workers, Village
Leaders and the Community. However, there was disagreement on the role of the Health Worker in
the waiver system. NGOs indicated that Health staff should be given the mandate to provide a waiver
so that patients can receive treatment immediately. Other resource persons felt that the health
workers should not have to decide on this. It was the general opinion that waivers were not an obvious
option for poor people.
Is CHF the solution?
Technical Paper 29