Health as a Productive Sector: Integrating Health and Industrial Policy

Health care is often represented as a purely “social” sector, implying that health care expenditure is a burden on the economy. We argue in this paper that on the contrary, health care is economically productive, and that health care in Tanzania could be much more economically and socially productive if health policy and industrial policy were more closely integrated. Increasing the depth and breadth of domestic economic linkages between the health services and industrial and commercial suppliers within the Tanzanian economy can strengthen economic development while improving health care. The paper begins by defining what we mean in this paper by “health services”, “health care” and “health sector”. It then examines the economic size of health care (production and financing), the employment it generates, and its linkages to the wider economy through procurement and wholesaling. It demonstrates that the health sector, broadly defined, is economically important as a major service sector, a location of investment, a generator of employment and income, a sector of skilled training and employment, and a location for industrial growth. The health of the health sector is very important for the health of the wider economy. The rest of the paper analyses the linkages between health care and manufacturing in Tanzania in more detail. It traces the declining share of local manufacturers of medicines and other health supplies in the expanding Tanzanian domestic market, quantifies the scale of this missed opportunity for industrial development to supply the needs of health care, and examines its causes. Finally, the paper looks at the scope for integrating health and industrial policy, arguing that reconstruction of these domestic economic linkages is both possible and desirable. Health policy strongly influences industrial development. Furthermore, the Tanzanian public health services suffer severely from shortages of essential supplies. We argue that it is possible for economic and social policy, working together, to strengthen and deepen economic ties within the economy, to the benefit of both the effectiveness of health services and public health, and manufacturing employment and development

Payments and Quality of Ante-Natal Care in Two Rural Districts of Tanzania

This paper surveys women’s experiences with payments for ante-natal care (ANC) and associated issues of quality in two rural districts of Tanzania. We draw on quantitative and qualitative data from interviews in facilities and in households in the two districts to explore these issues, and discuss some policy implications. The paper provides evidence of payments for ANC in the two rural districts. Striking differences in payments between the two districts were observed, apparently reflecting variation in charging practices in different parts of the districts. In the areas surveyed in one district, women were paying little, in both faith-based organisations (FBOs) and in the public sector. In the other district, charges were much higher in facilities that women had attended, including a district hospital and a public dispensary that seemed to have gone into business on its own account. We explore to what extent these higher charges were associated with better-quality care: The women in the higher-charging district had in general received somewhat higher levels of service than the women interviewed in the lower-charging district, with the notable exception of a low-charging FBO-owned hospital that was succeeding in combining low and predictable charges with good services. In both districts, we found few reports of abuse at the ANC level – this appears to be more a problem at birth. The main quality issues at this level are lack of basic ANC services in some of the public health facilities, and having to pay for ANC even in some of the public facilities where these services are supposed to be provided for free. However, the problem of supply shortages seems to have generated a system of informal charging in some contexts. Sale of assets and borrowing to pay for ANC means impoverishment in order to access a payment-exempted service. We also found that health insurance appears to be creating or supporting a culture of charging for ANC. ANC accessible to all women is a key requirement for improved maternal survival. The findings discussed in this paper suggest the need for a more concerted effort to implement effectively strategies that are already in place, and to come up with other alternative strategies that may result into better outcomes. Such strategies should not be considered in isolation, but should be part of effective strategies to improve all aspects of maternal health. Furthermore, an emerging problem needs to be looked into, and appropriate action taken. Health insurance, which is intended to promote access to health care for the poor, seems in this case to be creating a contrary effect by exacerbating the problem of payments for services that should be exempted from payment.\u

Upgrading under globalization in health-related industries in Tanzania: the case for dynamic industrial deepening

Globalization of markets and production networks has made it progressively harder for low income countries to industrialize. This article addresses a conundrum facing industrial firms and industrial policy in a low-income African country: how to achieve upgrading necessary for sustained competitiveness. Using data from a study of manufacturers of health products in Tanzania, we document the double ‘squeeze’ on firms’ profits exerted by sharp price competition alongside competitive pressure for rising product quality within globalized markets. Drawing on Sutton’s model of competing on capabilities, and the sectoral systems of innovation and production framework, we argue that ‘dynamic industrial deepening’, strengthening domestic inter-firm linkages, is a key requirement for sustainable development of these health industries. We present evidence that sectoral industrial support for the health industries can promote sustainable technological upgrading, and reflect on the challenge of building developmental linkages where external investment to support upgrading is transforming existing business structures

Rethinking health sector procurement as developmental linkages in East Africa

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012–15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa

Health-industry linkages for local health: reframing policies for African health system strengthening

The benefits of local production of pharmaceuticals in Africa for local access to medicines and to effective treatment remain contested. There is scepticism among health systems experts internationally that production of pharmaceuticals in sub-Saharan Africa (SSA) can provide competitive prices, quality and reliability of supply. Meanwhile low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. We present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. We then identify key policies that can ensure that local health systems benefit from the investments. We argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. We argue that this local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions

Institutional cultures and regulatory relationships in a liberalising health care system: a Tanzanian case study

This paper examines the formal and informal regulatory relationships that shape the Tanzanian health care system. The main focus of the paper is on the consequences of norms of organisational culture and the nature of informal regulatory relationships for inequity and exclusion

Starting from here: Challenges in planning for better health care in Tanzania

Health sectors are social and economic institutions. They reflect the broader political economy of their country, and contain within them the economic characteristics, power relations and hierarchies of the broader society – while also, strikingly, providing a location for redistributing resources, responding to need, and contesting disadvantage and exclusion. This chapter addresses the challenges facing Tanzanian health planners in seeking to move to universal health coverage from the current state of Tanzanian health care. It aims to contribute to building understandings of the scope for developmental planning for better health that is context- and place-specific in strategy while focused on practical problem-solving

Inequality and redistribution in health care: analytical issues for developmental social policy

This chapter contends that there is a need for more and better political economy of social policy in the development context, and seeks to contribute to its development. It discusses the problem of achieving and sustaining redistributive health care in contexts of inequality and low incomes. Much of our evidence and specific argument are drawn from the health sector in Africa, and in particular from research on health care markets in Tanzania. We believe however that our arguments have wider resonance for the effort to create effective, context-specific developmental social policy

Gender and health sector reform: analytical perspectives on African experience

This chapter argues that despite the silences, health sector reform models are implicitly gendered: that is, they have gender built inaudibly into their assumptions. The chapter explores analytical approaches the gendered nature and impacts of health sector reform: gender equity, women’s health needs and gendered health systems frameworks. Our objective is conceptual: to examine health sector reform through a gender ‘lens’, considering how the reform framework is gendered and the extent to which that gendered process may operate to the detriment of women, especially poor women. We illustrate our arguments with empirical evidence drawn largely but not exclusively from Africa, and consider implications of the analysis particularly for the African context