Poor People’s Experiences of Health Services in Tanzania

\ud Tanzania faces serious challenges to improving the health and well-being of its people. The Ministry of Health and its partners in government, the donor community and civil society have responded with concerted action, in many cases achieving significant gains. Services for prevention of mother-to child transmission of HIV are being expanded, a new protocol for malaria treatment is being implemented and evaluated, hundreds of service providers are now trained in life-saving skills for childbirth, and all districts have been oriented to the programme of integrated management of childhood illnesses (IMCI). These are but a few of the successes in recent years (MoH 2004a). These achievements are particularly notable given serious funding limitations in the health sector. The allocation to health has increased only slowly over recent years, from 7.5 percent in fiscal year (FY) 2000 to 8.7 percent in FY03, which is low in relation to projections in the Poverty Reduction Strategy (PRS) and to the Abuja commitment of 15 percent. Again, despite the PRS commitments, the absolute budgetary increase year-to-year has declined from a high of 41.12 percent in FY02 down to a 5.68 percent increase in FY04 (MoH 2004b). The FY05 budget ceilings indicate that the health sector will actually have fewer resources in real terms than in FY04. However, the low level of funding does not categorically preclude improvement of health services and ultimately health outcomes. “Differentiated” allocation of government funds, including in the health sector, can better prioritise the needs of the poor. The continuing disparities in health outcomes between the poorest and the richest Tanzanians and those in rural versus urban areas need to be addressed, along with the barriers to service experienced by the poor due to distance, formal and informal health charges, and other obstacles reported in this review (R&AWG 2003). The new resource allocation formula that utilizes equity criteria to distribute funds across districts, and the increasing proportion of funds for preventive services, are both positive developments in reaching the poor. Nonetheless, additional actions are needed to mobilize meaningful change for Tanzanians living in poverty. To move beyond policies and guidelines. To make tough decisions about how to bring the poor into the mainstream of health services, to focus differentiated attention to their well-being, and to bring critical human and financial resources to bear in one of the most crucial areas of Tanzania’s development: the health of its people. This literature review examines key findings on poor people’s experiences of health services and includes a particular focus on the barriers to access among the very poor due to cost sharing, an issue of special interest in the current era of “pro-poor” development. The review highlights seven key issues for reflection – and action: Access: Health services are often not accessed by the very poor, and by women in particular. Key obstacles are health care charges, long distances to facilities, inadequate and unaffordable transport systems, poor quality of care, and poor governance and accountability mechanisms. There have been improvements in availability of drugs which is a positive development, but some continuing deficiencies and particularly the cost of drugs still make them unavailable to many poor people. The shortage of skilled providers, while a serious concern to all actors in the sector including government, continues to persist. Discrimination against clients who are not able to pay and poor referral systems all result in low quality of care. Health care charges: Revenue generated by cost sharing has not necessarily impacted positively on quality of health care. User fees are not the only charges; other costs include transport costs, other “unofficial” costs including bribes, payments for drugs and supplies, and time spent away from productive activities which is particularly critical for people living in poverty. Health care charges have placed an impossible financial burden on the poorest households; many fail to access primary care when they need it most and many more fail to obtain the necessary referral for more skilled care. People do not always know what they are supposed to pay, and which payment demands are legitimate or illegitimate. Official charges are not necessarily affordable. “Unofficial” charges are still in place, and exemption and waivers have not been effectively implemented. The quality of care in public facilities has not necessarily improved even with the additional funds generated from user fees. The Community Health Fund may have improved the quality and range of services in those places where the CHF is in place. However, the scheme is not necessarily benefiting the very poor in a more equitable way. Many report they are not able to afford the joining fees and therefore pay for treatment on a case-by-case basis, which can ultimately be more expensive. more expensive. Participation and decision-making: Community participation is very limited in regards to determining health care priorities, deciding where funds should be allocated, and monitoring expenditures. This is a problem across priority sectors, not only in health. It is due in part to a general lack of knowledge about rights and recent reforms. More importantly though, reliable mechanisms are not in place for discussing issues of concern at the village level and then raising these concerns to the district level for action. Governance and accountability: Health consumers express dissatisfaction with critical governance issues such as abuses of power, financial mismanagement and corruption. While there exist some cases of health users and authorities working together, systems are generally not in place to ensure that services respond to the priority needs of beneficiaries. Adequate management systems have not been instituted to ensure appropriate collection of fees and allocation of these locally-generated resources. Government has recently begun to publish information on priority sector allocations for each district; this is an important development in enabling people to monitor public funds earmarked for critical services. Because this information is not disaggregated below the district level, however, it is not possible to monitor expenditures at the village or facility level. Exemptions and waivers: Exemptions, and in particular waivers, are not systematically implemented and are not effective as a means of protecting vulnerable social groups and the poorest of the poor. Even if official fees are exempted or waived, the poor and vulnerable still end up having to pay for drugs, transport, small charges (e.g. cards, materials), and bribes. The exemption scheme is poorly implemented partly because accountability mechanisms are not in place, and because health service providers are not following procedures that are often unclear to them to begin with. But an equally important factor is the low uptake and lack of insistence on free services by the poor, primarily because they are not aware of their rights. A lack of clear criteria and policy guidelines for identifying people who are eligible for waivers has resulted in ad hoc decisions, without clear records or follow-up. How poor people cope: Many poor households have fallen deeper into poverty as they end up using their limited and critical assets to pay for treatment. They use meagre savings (if they have any) and sell their crops, animals, land and their labour. Those who can, borrow money or take a loan, or bond their assets. They are often forced to reduce their food intake and to take their children out of school in order to pay for treatment. These strategies to pay for care drive poor people deeper into poverty and increase their vulnerability significantly. Health care seeking behaviour and choice of providers: Typically, poor people’s incomes are sufficient for subsistence only. They are frequently forced to resort to self-treatment, seek ineffective alternatives, or report much too late for care, often with fatal consequences. Many resort to traditional healers. If people can afford treatment at all, government facilities are normally the only option, especially in rural areas, as they may be close by and possibly less expensive. The overall feeling, however, is that if money can be found it is best to spend it at mission facilities which are generally known for staff commitment and availability of drugs and tests, but perhaps most importantly, for their willingness to defer payment and start treatment if necessary. The way forward The health sector is seriously under-funded despite the fact that it is a priority sector in the Poverty Reduction Strategy, and despite the fact that a healthy population is a basic ingredient of economic growth. Lack of funds, however, is not the only cause of the weak health system. Underskilled and de-motivated personnel, deficiencies in quality of care, weak and confusing management systems, lack of information provided to health consumers, and lack of access by the very poor to treatment characterize much of the current situation. These factors, and more, have resulted in a health care system that requires not only massive investments of funds but also a renewed commitment funds but also a renewed commitment and vision among all actors – government, policymakers, donors, non-governmental organizations, faith based organizations, health workers themselves and others – to generate fundamental change. This call for change is a particular imperative for Tanzanians living in poverty, for whom treatment is becoming increasingly unavailable, and for whom expensive private care is simply not an option. The dilemma, then, is how to make quality care available to all – including the poor – in an environment of limited and insufficient financial resources and severely constrained human and material resources. A number of questions have been raised in this report that merit immediate consideration: What mechanisms can be instituted to minimize the exclusion of poor and vulnerable persons from health services while recognizing the very real financial requirements of the sector? What are the main priorities for improved quality of care for the poor? Affordable services? Available essential drugs? Well-equipped facilities? A motivated team of skilled health workers? How can existing cost structures be revised in order to increase poor people’s access to quality health care? How can an effective mechanism of waivers and exemptions be instituted and enforced? How can problems of access to health facilities be addressed, including distance and affordable transport? How can the referral system be improved so it functions effectively even in rural areas? How can ordinary people get access to adequate and understandable information about allocations and expenditures at the local level? How can people be included in monitoring of health services and ensuring services are\ud \ud \u

Methods For Fuzzy Demand Assessment For IT Specialties

The rapid development of information technologies and their penetration into various spheres of human activity cause a sharply increased demand for IT specialists, in many countries of the world far exceeding the supply on them. High rates of technological transformation contribute to the diversification of the IT segment of the labor market, on the one hand, stimulate the disappearance of some and the emergence of new IT specialties, on the other. This creates a discrepancy between the structure of IT-related education and the labor market demand for IT specialists of the required profile and determines the relevance of developing methods for assessing the demand for IT specialties.This article is devoted to the study and solution of the problem of identifying the demand for IT specialties in the absence of accurate and complete information about the situation in the IT market segment. For the assessment of IT specialties and their ranking by the degree of demand in the labor market, the tasks of making individual and group decisions in the context of fuzzy initial information are formulated and solved. The methodological basis of the tasks posed is multi-criteria decision support methods based on fuzzy relations of expert preferences.The proposed approach as a mathematical tool for minimizing the structural imbalance of supply and demand for IT specialties is one of the components of the system of intellectual management of the labor market of IT specialists. The latter is designed to support the adoption of scientifically based management decisions to eliminate the mismatch of supply and demand in the IT segment of the labor market in professional, quantitative and qualitative sections

What are the implications for global value chains when the market shifts from the north to the south?

Rapid growth in many low-income economies was fuelled by the insertion of producers into global value chains feeding into high-income northern markets. This paper charts the evolution of financial and economic crisis in the global economy and argues that the likely outcome will be sustained growth in the two very large Asian Driver economies of China and India and stagnation in the historically dominant northern economies. Given the nature of demand in low-income southern economies, it is likely to be reflected in sustained demand for commodities, with other southern economy producers in global value chains being forced into lower levels of value added. Standards are likely to be of considerably reduced significance in value chains feeding into China and India

What are the implications for global value chains when the market shifts from the north to the south ?

Rapid growth in many low-income economies was fuelled by the insertion of producers into global value chains feeding into high-income northern markets. This paper charts the evolution of financial and economic crisis in the global economy and argues that the likely outcome will be sustained growth in the two very large Asian Driver economies of China and India and stagnation in the historically dominant northern economies. Given the nature of demand in low-income southern economies, it is likely to be reflected in sustained demand for commodities, with other southern economy producers in global value chains being forced into lower levels of value added. Standards are likely to be of considerably reduced significance in value chains feeding into China and India.Economic Theory&Research,Climate Change Economics,Labor Policies,Emerging Markets,Markets and Market Access

METHODS FOR FUZZY DEMAND ASSESSMENT FOR IT SPECIALTIES

The rapid development of information technologies and their penetration into various spheres of human activity cause a sharply increased demand for IT specialists, in many countries of the world far exceeding the supply on them. High rates of technological transformation contribute to the diversification of the IT segment of the labor market, on the one hand, stimulate the disappearance of some and the emergence of new IT specialties, on the other. This creates a discrepancy between the structure of IT-related education and the labor market demand for IT specialists of the required profile and determines the relevance of developing methods for assessing the demand for IT specialties. This article is devoted to the study and solution of the problem of identifying the demand for IT specialties in the absence of accurate and complete information about the situation in the IT market segment. For the assessment of IT specialties and their ranking by the degree of demand in the labor market, the tasks of making individual and group decisions in the context of fuzzy initial information are formulated and solved. The methodological basis of the tasks posed is multi-criteria decision support methods based on fuzzy relations of expert preferences. The proposed approach as a mathematical tool for minimizing the structural imbalance of supply and demand for IT specialties is one of the components of the system of intellectual management of the labor market of IT specialists. The latter is designed to support the adoption of scientifically based management decisions to eliminate the mismatch of supply and demand in the IT segment of the labor market in professional, quantitative and qualitative sections

China's structural demand and commodity super cycle: implications for Africa

The 2003-08 commodity price boom, also termed as a super cycle, was driven mainly by China's demand for commodities to fuel its domestic infrastructure and manufacturing growth. This chapter examines the 2003-08 period, contrasted with the previous two commodity booms in 1951-53 and 1973-75 in order to learn if the latest boom was unique in any manner. We then look at the nature of China's structural demand and its future needs. Finally we highlight the implications of the commodity price fall for African countries, in relation to Chinese demand in the near future

What happens in global value chains when the markey shifts from the north to the south?

This paper charts the evolution of financial and economic crisis in the global economy and argues that the likely outcome will be sustained growth in the two very large Asian Driver economies of China and India and stagnation in the historically dominant northern economies. Given the nature of demand in low income southern economies, it is likely to be reflected in sustained demand for commodities, with other southern economy producers in global value chains being forced into lower levels of value added. Standards are likely to be of considerably reduced significance in value chains feeding into China and India. These issues are considered in the light of evidence drawn from the experience of Thai exporters of cassava, and Gabonese exporters of timber

The association between dental caries and anthropometric measures in 5-9-year-old Bangladeshi children

BACKGROUND: Dental caries is the most common childhood disease worldwide. Previous research on the associations between dental caries and height, weight and body-mass-index (BMI) among children has produced inconsistent results. Dental caries also has a negative impact on oral health related quality of life (OHRQoL) in children. However, the precise nature and underlying mechanism of this relationship is yet to be fully investigated. Thus the PhD thesis aimed to assess the associations between dental caries and anthropometric measures (height, weight and BMI) among 5-9-year-old Bangladeshi children. A secondary aim was to examine whether any associations between dental caries and anthropometric measurements were explained by OHRQoL, in particular dental pain, eating difficulty, poor appetite and sleep disturbance. METHODS: A cross sectional observational study was conducted among 5-9-year-old children in Dhaka, Bangladesh. Data were collected from children and their parents from Dhaka Dental College Hospital and from three nearby primary schools. Multiple linear regression analysis was used to assess the associations of interest, adjusted for potential covariates. RESULTS: The final sample comprised 788 children. Dental caries and sepsis showed negative associations with height-for-age z-scores (HAZ), weight-for-age z-scores (WAZ) and BMI-for-age z-scores (BAZ) after adjusting for all confounders. Children who had higher level of caries and sepsis had lower HAZ, WAZ and BAZ compared to caries and sepsis free children. Adjusting for OHRQoL led to significant attenuation on associations between dental caries, sepsis and anthropometric outcomes. Moreover, OHRQoL showed significant inverse association with weight-for-age and BMI-for-age but not with height-for-age. Finally, amongst all potential mediators, adjusting for dental pain and eating difficulty led to significant attenuation on these associations. Therefore, dental pain and eating difficulty might be considered to partly explain the inverse associations. However, only eating difficulty showed significant inverse association with weight-for-age and BMI-for-age but not with height-for-age. Thus OHRQoL particularly eating difficulty might be considered on the hypothesized pathway of negative associations between dental caries, sepsis and weight-for-age and BMI-for-age. CONCLUSION: The results of this study provide evidence that dental caries was associated with lower height, weight and BMI among the study population. Secondly, OHRQoL particularly dental pain and eating difficulty partly explained the negative association

Law of Murder under Islamic Criminal Law: An Analysis

Islam considers murder to be the most heinous crime against a person. The blood of a human being is sacred in Islam. Prophet Muhammad (SAW) reportedly stated that the first act of Allah on the Day of Judgment would be to punish murderers by making them suffer the torment of Hell. Prophet Muhammad (SAW) at his last pilgrimage declared that the blood of human being, their property and prestige are as sacred as the city of Haram of Makkah and the day of Arafah. Undoubtedly the greatest crime known to mankind is murder. It has been punishable under all systems of law since early in the history of mankind and throughout the ages up to the present. This article explores the law of murder and its punishment under Islamic criminal law. It also examines the origin of punishment and way of proving of Islamic criminal law of murder. Keywords: Islamic Criminal Law, Homicide, Punishment of Islamic Law, Retaliation, Blood-money