equity implications of health sector user fees in tanzania

this way the health centre prevents that they have accumulated bills which people cannot afford.
� The HC does not have a fund for poor people. Sometimes the Congregation provides support to poor
people and will settle the bill from a poor fund.
� CHF participation is encouraged. The CHF refund is smooth and people can receive services up to a
certain ceiling. The Congregation has paid the CHF premium for a few patients.
Table TP 24: Views of 10 NGOs towards impact of User Fees, March 2004
� The majority (10) was well informed on the elements of the Tanzanian user fee system.
� The majority (10) was able to mention the groups entitled to exemption of user fees (e.g. under-fives,
pregnant women, TB patients and HIV clients) and waivers (the poor people).
� The majority (7) feels that poor people have more access to the public health services then to private
health services because of the level of user fee charges (the fees are higher in the private HFs). The
poor also have a higher chance to get a waiver in a public facility then in a private facility. If people can
afford, they do prefer the private HFs.
� The majority (8) feels that there is a negative impact of user fees on poor people. Especially orphans,
widows, AIDS patients, elderly and people with disabilities cannot afford to pay for the services. Even
Tshs. 500/= for a card is difficult to pay. It is observed that also under-five children and pregnant women
face problems. The main problems are seen in the rural areas. The consequence of the inability to pay
user fees is that people resort to (1) delayed treatment which leads to complications, (2) inadequate
treatment, (3) increased morbidity and mortality, (4) traditional medicine, (5) sale of property, (6) child
labor, (7) theft, (8) starvation to save money. The economic impact of user fees on families is
substantial. The majority of NGOs feels that the exemption and waiver systems do not function.
� The majority (7) feels that people do not have equal access to health services due to (1) poverty, (2)
absence of HFs in areas, (3) geographical barriers and distance, (4) bribery practises, and (5)
demotivated health staff in some areas.
� Gender plays a role because of (1) dependency on the husband for income and the use of his bicycle
for transport, (2) less confidence in health professionals, (3) limited education, and (4) not willing to
leave the house unattended to seek health care.
� The majority (7) declined from the introduction of user fees because of their mandate to assist the
poorest people in the project area. The NGOs provide free or subsidized health services with support
from external funders. One NGO decided that, since the programme budget was reduced, the
guardians of orphans (even though they are poor) had to pay 50% of the health costs. This decision
contributed to a reduced attendance in the NGO clinic by guardians.
� The FBOs (Catholic and Lutheran) participate in a CHF and collaborate together.
� The majority of the NGOs (7) have not registered patients in a CHF.
� The majority (8) of the NGOs has no experience with a CHF but the CHF is considered as pro-poor.
Table TP 25: Experiences with the Exemption and Waiver system by resource persons, March 2004
� For a poor person being sick means trouble.
� 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. The waivers are not an obvious
option for poor people.
� A waiver system is not transparent. The exemption and waiver procedures are too bureaucratic and
should be made more straight forward. People who require a waiver often do not get it while big shots
manage to get free or subsidized treatment. The Social Welfare people are not helpful to poor people.
� NGOs indicate that the exemption and waiver procedures are stigmatizing the clients.
� The identification of people who can not pay is difficult.
� People who are best placed to assess the ability of poor people to pay and the need for a waiver are for
example; Social Welfare Officers, Health Workers, Village Leaders and the Community.
� There is disagreement on the role of the Health Worker in the waiver system. NGOs indicate that Health
staff should be given the mandate to provide a waiver so that patients can receive treatment
immediately. Other resource persons feel that the health workers should not have to decide on this.
People will try to win the sympathy of the health worker and will come in a shabby appearance to let
people think that they are poor.
Table TP 26: View of the Social Welfare Officer Bukoba Regional Hospital towards Exemption and
Waiver system, March 2004.
� In the Regional hospital the Social Welfare Officer 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.
anesthetics), taking care of referral of “dumped babies” to an orphanage, refer the “helpless” and the
“loitering” to an elderly home.
� The exemption and waiver guidelines are clear but there are problems; (1) people pretend that they are
poor while they are not, (2) rich people with chronic diseased 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 get an waiver.
The exemption/waiver card is only for hospital services.
Technical Paper 34