equity implications of health sector user fees in tanzania

Table TP 20: NGO clinics (2) and user fees, March 2004
� The guardian has to pay 50% of the medical costs (on average between Tshs 1,500/= and Tshs
2,000/=). As a result the attendance of guardians reduced. If guardians cannot afford to pay cash, they
can pay in kind (e.g. food). The food is provided to the children in the day care centre. Guardians prefer
to visit the Government facility since the dispensary requires a flat fee of Tshs 500/= for the total
service.
� The NGO programme (external funding) pays all (100%) the health costs for the orphans
� Children not covered by the programme pay 100% of the total costs. Not many children outside the
programme visit this clinic.
Table TP21: Views of 19 Health Workers towards impact of User Fees, March 2004
� Are well informed on the National User Fee system and are informed on Government criteria for
waivers: (1) Disabled, (2) People older then 60 years, (3) Mentally handicapped people, (4) Depending
on conditions. Most of the respondents mix the words exemption and waiver.
� More people make use of the public health facilities compared to the private facilities. This is related to
the fee levels. The private facilities are not considered ethical since they charge high fees and prescribe
extra expensive drugs.
� Poor people cannot afford the health services. They will not receive the required services. People may
resort to traditional herbs or may die. Especially elderly and disable people are affected. Pregnant
women can often not afford the delivery in HFs since they first will have to buy the items such as
razorblades, stitches, gloves, etc.
� User fees contribute to increasing services nearby the villages, availability of drugs, increased
ownership and will prevent misuse of drugs by people who are not sick. However, user fees have also
contributed to misuse of the money by those who are handling the funds. This has created a bad image
to the public. There are no bribes to be paid.
� If people know that the services are good, they will travel a long distance to that particular HF. Good
services include; consultation, laboratory, inpatient facility, safe deliveries and professional health staff.
Table22: Views of 2 private clinics towards the impact of User Fees, March 2004
� Groups affected by the user fees are the poor and the unemployed.
� People do not have equal access to health care services since HFs are not equally distributed. There
are clear geographical differences.
� Impact of user fees on poor people: (1) may not seek treatment at all and (2) may opt to visit a local
healer.
� Assistance by poor people may be found from the Social Welfare Office.
� The CHF is pro-poor and is a step forward in health coverage for poorer people.
Table TP 23: Views of 4 Catholic Diocese health resource persons towards user fees, March 2004
� User Fees are charged in the Diocese since 1912.
� User fees differ per health facility and can be decided by the Management Team (MT) in the HF.
� At all levels (hospital, health center and dispensary) services are charged except for MCH and TB
patients. The charges are differentiated (for consultation, laboratory, and treatment). Some health
interventions receive external donor funding.
� The user fees contribute to the running costs of the HFs. If people are unable to pay then this affects
the income of the HF.
� Fees have not been raised since 1997 due to the prevailing economic situation in the area (in
dispensary).
� Some areas in the Diocese are extremely poor (e.g. affected by war between TZ and Uganda,
HIV/AIDS, poor soil fertility, impact of El Nino rains in 1998).
� Most people who visit the HF are better off and better? manage to pay than people nearby the HF.
� Waivers can be given to people who are unable to pay. There is no formal waiver system in place. This
depends entirely on the health staff in the HF.
� In principle everybody has to pay but if one fails, we inform the village leaders, present the bill and wait
for payment afterwards. However, exemptions are given for TB patients, MCH services and ANC
services. Under-five children, elderly people and AIDS patients have to pay as well. Nobody is turned
away because he/she can not pay. However, poor people know that they cannot afford to pay the
services and will not come. If they come they will settle the bill afterwards or not at all.
� The current revenue generated does not cover the running costs of the facility. There is no formal poor
policy. We have to cover our running costs since we do not receive financial assistance from the
Diocese.
� The Health centre stopped payment of Tshs 5,000 upon admission since people could not manage to
pay this. Registration and investigation costs are compulsory upon admission but the other costs can be
paid slowly by slowly until the whole amount is recovered. This system works. If a person is very poor
and cannot pay then he will be given first aid treatment and will be referred to a government facility. In
Technical Paper 33