Equity Implications of Health Sector User Fees\ud in Tanzania : Do we Retain the User Fee or do we Set the User F(r)ee?

\ud Early 2004, Research for Poverty Alleviation (REPOA) commissioned ETC Crystal to examine the equity implications of health sector user fees in Tanzania, with particular reference to proposed and actual charges at dispensary and health centre level. This year, Tanzania will review its Poverty Reduction Strategy. With the findings of the user fee study, REPOA aims at making a valuable contribution to the review process and provide country-specific insight into one of the most debated issues in health financing. The focus and design of the study was formulated in close cooperation with the Research and Analysis Working Group of REPOA. The strategies for data collection comprised: (1) a comprehensive literature analysis literature, (2) semi-structured interviews with resource persons from the government of Tanzania, multi- and bilateral donors, research institutes and NGOs in Dar Es Salaam, and (3) a case study in Kagera Region, including both document analysis and semi-structured interviews with resource persons from the MOH, NGOs, FBOs, health workers and health care consumers from vulnerable and poor population groups. The study team developed multiple tools for data collection and analysis including: (1) a data matrix for categorisation and identification of key issues, (2) guidelines for the interviews in Dar Es Salaam, (3) guidelines for data collection and interviews in Kagera Region, and (4) a tool for the analysis of poverty reduction strategy documents. A total number of 170 user fee-related documents were assessed, including those covering the experience from neighbouring countries. Seventy-nine resource persons participated in the study. Resources generated by user fees and their use at hospital, district council and PHC levels. The study team found that reliable, transparent user fee income data for district, hospital and PHC level were difficult to obtain. Based on what information is available, the team concludes that revenues raised from user fees at the hospital level have been lower than what has been projected. Furthermore, the data reflect huge variations between facilities and a decline in the revenues from cost sharing. The reasons of the reported decline are unclear. The data reflecting the contribution of user fees and CHF to the health budget at district council level show huge variations as well. The reported user fee income proportion for the district health budget was on average 10.5%. The study team could not establish how the income from cost sharing and the CHF was re-distributed by the council to PHC facilities or priority areas. A worrying finding was that some councils did not spend all health resources in the health sector. The study team observes an urgent need for: (1) more accurate and comprehensive record keeping at local council level, and (2) more costing and tracking studies to obtain a better insight into cost sharing and expenditures and to adequately inform policy making. Contribution of user fees and CHFs to the health resource envelope. The study team concludes that the national projections of the cost sharing schemes do not reflect an accurate picture, since the data are based on the inaccurate financial data received from the districts. It is likely that the actual and projected data on user fees, CHFs and HSF are underestimations of the real income collected at the different facility levels. This means that the MOH faces a loss of income that cannot be redistributed to the health sector. It also implies that people (both wealthy and poor) are likely pay more than what is officially reported. The actual potential and use of the non-reported user fees are not known. The total contribution of the cost sharing schemes (excluding NHIF) to the national health resource envelope for FY03/04 is 1.67 Billion Tshs. This equals a contribution of 0.6% to the overall budget for the health sector. In total, this is US$1.56 million. Given the size of the total health budget (US$ 260 million), it can be concluded that the officially reported user fees contribute a small proportion only. The actual revenue generated does not meet the initial expectations. Contribution of revenues generated to improved services. The study team found limited positive evidence that user fees in Tanzania have in general achieved their original objectives of sustainability, drug availability, quality of care, equity and access for the poor. More specifically, the study team found that government-run PHC facilities appeared to face severe shortages of drugs and supplies. In addition, user fees were not always retained at PHC level, but deposited in the HSF account which mainly benefits the purchase of supplies for the district hospital. Positive results were seen for reinvestment of CHF funds. In total, 50% of the health workersand patients reported improvements in drugs availability, diagnostic facilities and maintenance. However, equity criteria for the distribution of available resources from the user fee income to PHC level are not systematically followed. Impact of user fees on access to health services. The study team concludes that presently, the user fees in Tanzania are regressive and contribute to substantial exclusion, self exclusion and increased marginalisation. The team has collected evidence which shows that user fees have disproportionally affected access to health care for poor and vulnerable population groups, more specifically: (1) pregnant women from poor households, (2) under-five children from poor households, (3) orphans and especially double orphans, (4) widows, (5) people older than 60 years, (6) people with disabilities, and (7) AIDS patients. Further extension of fees to dispensary and health centre level. Also at the PHC level, the study team found that fees have negatively impacted the use of health care by the rural poor population, particularly women and children. Given the importance of the public PHC facilities for poor people (government health centres are the main choice for out-patient care for the poor), the study team expects that the further extension of user fees to PHC level without effective exemption and waiver mechanisms will contribute to further exclusion and selfexclusion. Effectiveness of exemption and waiver mechanisms. The study team identifies the ineffectiveness of the present exemption and waiver mechanisms as the core problem in the user fee debate in Tanzania. A functional exemption and waiver system is actually non-existent putting vulnerable and poor people at risk by practically denying them access to public health\ud services. This applies both to (1) the exemption and waiver system in health facilities and (2) the exemption mechanisms instituted for the CHFs. In both situations, poor people just do not receive the exemptions to which they are entitled to! Revenue collection appears to prevail over protecting the poor and vulnerable. Some hospitals have even tried to hide the waivers in their statistics in order to have, on paper, a better performance with their user fee income. The study team recommends that, should the government of Tanzania decide to maintain its user fee policy, priority is given to the design of an effective exemption and waiver system combined with: (1) sufficient resources to compensate for the unknown money lost (since it not recorded properly), and (2) a serious effort to make it work. However, there is substantial evidence that exemption and waiver systems do not guarantee increased access to health services for poor people unless major adjustments in the design, implementation and funding for adequate exemption and waiver systems take place. In the light of recent developments in Uganda and Kenya, it seems a much more realistic approach to compare the costs of (1) the suspension of user fees at PHC level against the required costs for (2) improved exemption and waiver systems or (3) improved NSHIF approaches in the contest of abolishment of fees and to opt for the most pro-poor and cost-effective approach within the shortest possible time frame. The potential and impact of Community Health Funds. The introduction of the CHF has not provided the expected benefits for poor people. There are a number of constraints the study team thinks should be urgently addressed, including the delays in the introduction of the CHFs and the weak management at the district and lower levels. More importantly, the study team found that poor people often cannot afford to pay the CHF premium because it is too high and has to be paid at once. If membership of the CHF becomes compulsory and poor people are not effectively exempted from paying CHF premiums and co-payments, the impact of the CHF can be disastrous and lead to double exclusion of poor people. Another issue of concern is related to the link between user fees and the CHF. According to the CHF Act, the user fees paid at public health centres and dispensaries form a source of income to the CHF. The premium paid to the CHF will receive WB matching funds, putting pressure on the PHC facilities to raise income through user fees. This indicates a complicated dilemma since it means that if user fees will be suspended or abolished at PHC level, the CHFs will not be able to take off as planned and will not receive part of their required resources. This points to the need to assess the mix of financing mechanisms and their interactions, rather than look at them as stand-alone policies. Tanzania has opted for a system of multiple risk-pooling schemes for the health sector. There is an urgent need to review the ongoing processes and assess their impact on the overall health system and the vulnerable members of the population. Scenarios. Reviewing the available literature, the study team observes that the abolition of user fees for education in Tanzania, and for health in South Africa and Uganda, has had impressive results in terms of attendance and access. Recently, Kenya also decided to abolish user fees for health. However, when reviewing the stakeholder’s attitudes towards abolition, the study team concludes that the necessary support for such a decision seems to lacking in Tanzania at present. The study shows that Tanzania is at a cross road. Tanzania can opt for two strategic directions. One strategy can be to continue on the road of the multiple risk pooling strategies. The other strategy can be to follow the abolishment of user fees at either (1) all levels or (2) at PHC levels. Both strategies will require substantial support from external donors and will require major adjustments in the current funding mechanisms. However, given the negative equity implications for poor people with the multiple risk pooling systems and the complicated, time consuming, costly and unreliable administration that is required for user fee systems and CHF, evidence indicates that it seems a more pro-poor and pragmatic strategy to abolish the user fees for poor people either (1) temporarily till improved exemption and waiver systems have been designed and introduced or (2) as long as the poverty situation in Tanzania requires. In case Tanzania will opt for the continuation of a multiple risk pooling system, then a number of key conditions will have to be met in order to ensure access to health services for poor people. It will be crucial to assess the mix of financing mechanisms and their interactions rather than look at them as stand-alone policies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the commitment to reducing poverty in Tanzania as articulated in the PRS. Consequently, immediate political action is required. Abolition of user fees can be considered as a pro-poor option to reduce exclusion and self-exclusion among the poor and vulnerable. The studies illustrate, that the abolition of fees needs to be combined with considerable efforts in other areas, such as changed levels of funding (internally and externally), improvements in the allocation and disbursement of funds, improved human resource development, improved incentive schemes for health workers and improved quality of services. This indicates the importance of a broad, strong political support and donor support. The developments in Uganda and Kenya might have created a momentum for Tanzania to rethink the current multiple risk pooling strategies in the context of the PRS Review and to opt for more pro-poor health strategies. It should be noted that in the current political situation strengthening the existing exemption and waiver systems seems to be the most preferred scenario at this moment. However, in the light of all the constraints mentioned and in the context of positive developments in Uganda and recent decisions taken in Kenya, the study team would like to recommend to include the suspension of user fees at PHC level in the next PRS document for Tanzania as a real pro-poor health strategy for Tanzania. The study team considers the Poverty Reduction Strategy Review Process as an excellent opportunity to lobby the government and the development partners on these issues, and to demand that a specific Plan of Action is included in the second Poverty Reduction Strategy Paper. The study team hopes that the findings of this study will contribute in such a positive and constructive way to the Tanzania PRS Review Process. The outcomes of this study confirm that in Tanzania, user fees are an issue to be carefully (re)considered when designing national pro-poor health policies in Poverty Reduction Strategies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders\ud continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the government’s commitment to reduce poverty in Tanzania. Consequently, immediate political action is required.\u

Impact of cost and perceived quality on utilisation of primary health care services in Tanzania: rural-urban comparison

A cross-sectional study was carried out to assess the impact of perceived quality and cost of utilisation of primary health care services, in relation to malaria, in rural and urban districts in Tanzania. This study intended to explore whether there are differences between rural and urban users in terms of their perceptions of quality of health services and how these perceptions affect household decisions in utilising health services. The findings showed that socio-economic variables such as gender, income, education, wealth and household size were important in determining users' decision making on the amount and appropriate time to seek care and also mitigates effectively on the extent to which cost and perception of quality of care affect rural and urban users of health care services. The majority of rural households spent more time at the facility while waiting to be attended than urban users of health services. Female-headed households were more likely to use health care services more frequently than male-headed households. It was also shown that urban households used health care more frequently than rural ones; and lack of money was not as important as perceived quality both in relation to frequency in using nearby health facilities, and to the delay in seeking care. In conclusion, the perceived quality of health care services is a strong determinant of health care utilisation and it has a differential impact on utilisation of health services. Tanzania Health Research Bulletin Vol.6(2) 2004: 51-5

Effects Associated with Processing Ballast and Waste Oil at Port Reitz, Mombasa-Kenya

This study was carried out in response to a complaint regarding environmental pollution, arising from the processing of ballast water and waste oil on the premises of the landlord on Plot No. LR 1192/VI/MN, Port Reitz, Mombasa. The plot is designated commercial for purposes of land use purposes, and its tenant had been undertaking a ballast water/oil sludge scheming process to obtain fuel oil, which he sold to industrialists. This had resulted in damage to the environment as the facility incorporated no safeguard to address oil spills and no drainage system to contain waste discharges from the process. The study was undertaken to establish the level of environmental damage, propose rehabilitation costs, and offer recommendations for remedial measures. The study was realised through desk study, field visits, digging and sampling of soils for analysis. The results showed that between 60-70% of the soil in the premise was contaminated with oil, penetrating at least one meter deep. Effect from the oil contamination manifested in the failure of the soils to support growth of new vegetation, while existing tree plants were withered. The impact from this was the loss of aesthetic beauty of the property, reducing its amenity value. Percolation of oil underground in porous rock formation has potential to contaminate groundwater, threating the quality status of this resource for domestic purposes. The process activities were also of health concern since no safeguards had been provided to protect the workers from direct contact the oil. Hydrocarbon oils when exposed to hot climatic conditions like those prevalent in Mombasa, which provide high solar radiation have the potential to breakdown, emitting some toxic and potentially carcinogenic substances. The facility therefore exposed the workers to the dangers of contracting cancer through inhalation of the emissions with potential long term health consequences. Finally, the massive physical environmental damage on the premises means rehabilitation costs could be high. Estimates indicated that as much as US$100,000 would be required to restore the premises to a condition that would allow natural regeneration. The findings also indicate that the activity being undertaken, is not the best land-use for the area. It is consequently recommended that if the activity must continue, then it must be conducted according to established guidelines. Otherwise, it is ideal that it is ceased, and rehabilitation works, commenced. It is also observed that important potential effects were not included in this research. Ballast water is known to introduce invasive species. Efforts therefore need to be undertaken to determine the presence such species in the neighbourhood before they attain pest proportions. Keywords: Ballast water, MARPOL, oil sludge; air, soil and groundwater contamination, environmental damage, health effects, toxic substances carcinogenic products.

The Effects and Impacts of Quarrying on Forest Land: the Case of Gami Quarries, Mwache Forest, Kwale County, Kenya

This paper highlights the effects and impacts of quarrying on Forest Land, with Mwache Forest, located in the Kwale County, whose land use is defined as conservation –as the study case. Despite the defined land-use, Gami Quarries Ltd had been given the rights of exploiting the rock out-crop in the forest to make ballast –a raw material needed in the construction industry. Ballast processing operations were initiated through blasting the rock structure using explosives inserted onto holes drilled on the rock, disseminating it into boulders that were sized into smaller rocks that were transported for processing into ballast. The explosions resulted into the generation of wave energy that weakened the rock formation and, damaged the existing neighbouring infrastructure; it produced dust and higher levels of noise. Transport of the rock material for processing into ballast, resulted in the emission of fugitive dust due to tracking on the unpaved road. This was in addition to the emission of the oxides of nitrogen and sulphur, carbon monoxide, suspended particle matter (SPM) and, volatile organic compounds (VOCs) from the poorly maintained diesel engine powered tracks. The significance of air pollution from the ballast-making operational processes was low, bearing the wind regime, which scattered and diluted the pollutants. Run-off from the quarry spoils however introduced undesirable elements in water; while lack of sanitation on-site was recipe for transmission of water borne disease. Quarrying for ballast exposed the groundwater aquifer, making it vulnerable to contamination; it at the same time led to the potential of altering the existing drainage characteristics, interfering with stream flow and aquifer recharge. Quarrying created Bad Lands, exposed the bed rock to erosion and reduced the moisture content usually experienced in forested land with impact on local ecology, arising from the destruction of the habitat. The effects of enhanced noise from the blasting operations was traced into hearing loss among the workers; the noise also disturbed wildlife and grazing animals. Fire-outbreaks were also potential due to the explosives use, it could also result from the domestic activities of the workers. Fire outbreak on dry forest could lead to severe and significant effects, including the loss of life. On occupational health and safety matters, the workers have had to do with the consequences of potential exposure to dust, potential injuries from flying blasted rock debri, from the impacts of water borne and, water related diseases and, high levels of noise. To minimize the identified effects and impacts, operating rules had been given. These offered adequate protection. However, it was recognized that the rules and procedures ought to be engraved into an Environmental Management and Monitoring Plan in order to promote sustainability of the actions. This had not been done. Key words: quarrying, dust, noise, pollution, habitat destruction, water borne and water related diseases, cancer, operating rules and procedure

Chemical Cues for Malaria Vectors Oviposition Site Selection:\ud Challenges and Opportunities

The attractiveness of oviposition site for malaria vector mosquitoes is dependent upon a number of physical and chemical factors. Many aspects of mosquito behavior, including host location and oviposition, are mediated by volatile semiochemicals. It is anticipated that selection of oviposition site by semio-chemicals in the form of attractants or stimulants can be used in oviposition traps to monitor or possibly in combination with insecticides to control gravid mosquito populations for mass trapping. So far, volatile compounds identified as oviposition attractants for mosquitoes include phenol, 4-methyl phenol, 4-ethyl phenol, indole, skatole, and p-cresol from hay infusions; 3-carene, terpinene, copaene, cedrene, and d-cadinene released by copepods; alcohol and terpenoids including p-cresol fromplants; ethyl acetate and hydrocarbon substances, probably released by filamentous algae; 3-methyl-1-butanol identified frombacteria. Research priorities should be directed at identifying more oviposition attractants to determine the properties of these semio-chemicals for possible use in designing control tools. This would aim at luring females to lethal traps or stimulants to increase their exposure to insecticide-impregnated substrates.\ud \u

Covid-19 and border restriction policies: the dilemma of trans-border truck drivers in East Africa

Purpose: The purpose of this paper is to critically assess the challenges that were faced by trans-border truck drivers within the East African Community as a result of the Covid-19 pandemic and its management protocols. Research methodology: While adopting the qualitative research method, this paper has used documents including documented interviews and virtual sources for its data. The data have been analyzed using qualitative content analysis through which themes have been generated for discussions. Results: The EAC member countries should continue to harmonize their health standardization to enable them to enjoy the pursuit and use of OSBP even during pandemics. Limitations: This paper, however, is limited to the long-distance truck drivers and the management of Covid-19 within the East African Community and does not cover other aspects of Coordinated Border Management in the region. Contribution: It provides valuable contributions to the need for harmonization and standardization of operations and health measures within the community as a long-term solution to the challenges of coordinated border management within the community in the face of future pandemics and readiness for the single market regime. Keywords: Truckers, Coordinated border management, Covid-19, East African Community, Relay drivin

Determinants of Developmental Milestones among Children 0-23 Months at Kabale Hospital, Uganda

Background: Approximately 200 million children globally fail to fulfil their development potential due to malnutrition, poor health, and unstimulating environments. Children in Kabale, Uganda, may be at particularly high risk as the rate of malnutrition in the region is likely to impact development. The study aimed to identify possible determinants influencing developmental milestones of breastfed and non-breastfed children aged 0-23 months.Materials and Methods: The study was conducted at the young child clinic of Kabale hospital, among 250 children aged 0-23 months and their caregivers, for two months. The study adopted a comparative cross-sectional design, and systematic random sampling was used to select the respondents for the study. The socio-demographic characteristics, nutritional status, and feeding practices were assessed using structured pretested questionnaires. Developmental milestones of the children (communication, motor, fine motor, problem-solving, and social skills) were assessed using the modified ages and stages questionnaires. The data collected was tabulated, analysed statistically, and the results interpreted.Results: Developmental scores were not associated with breastfeeding and minimum meal frequency. A milestone achievement of communication skills was associated with caregiver's education, caregiver's age and length-for-age. Gross motor scores were associated with the caregiver's age, weight-for-age, and length for age. Achievement of fine motor skills was associated with caregiver's education, caregiver's age, child's age, length for age, and children who met the minimum dietary diversity score. Problem-solving scores were associated with child's age, weight for age, length for age, and children who met the minimum dietary diversity. Personal social scores were associated with lower caregiver's age and normal weight for ageConclusion: Developmental scores were not associated with breastfeeding and minimum meal frequency. Development in early childhood was mainly associated with caregiver's age, caregiver's education, child's age, weight for age, length for age, and minimum dietary diversity score. Children under the care of younger caregivers and those who attained normal nutrition status had significantly more developed motor and social skills compared to children with older caregivers and undernourished children, respectively. Recommendation: Meeting the minimum meal frequency is commendable; however, caregivers should also strive to meet the minimum dietary diversity, which ultimately contributes to a better nutritional status and hence development in children. Older caregivers should be educated on the importance of developmental milestones and their contribution to optimum development in children